CA Home Care License # 364700124 First Name Last Name Date Street Address Street Address Line 2 City State / Province Postal / Zip Code Please enter a valid phone number. Driver’s License / ID State Date of Birth Email Address Have you ever applied for employment with this Agency? YesNo Are you legally eligible for employment in the United States? YesNo How did you learn of our organization? Newspaper AdAgency employeeOther HOURS AVAILABLE TO WORK SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY LIST BUSINESS SCHOOLS, COLLEGES ATTENDED AND ANY RELATED CLASSES LOCATION DEGREE YEARS LOCATION NAME OF SCHOOL Educational Background School Name / Location Major Yrs of Study/Degree College / Graduate Vo-Tech / Trade High School Others 1. Company Name: Telephone: Starting Pay: Ending Pay: Job Title and Describe Work Completed: Reason for leaving: 2. Company Name: Telephone: Address: Dates of Employment: Starting Pay: Ending Pay: 1. Reference Full Name Phone City State If Professional Reference: Position Held If you answered No, which job requirement can you not meet? List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience. CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED Signature Date APPLICATION FOR EMPLOYMENT All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential. PERSONAL INFORMATION Name* First NameLast Name Date -Month -DayYear Date Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Home Phone Number* Please enter a valid phone number. Social Security Number* Driver’s License / ID* This field is required. State* Date of Birth* -Month -DayYear Date This field is required. Email Address example@example.com Have you ever applied for employment with this Agency? YES NO How many hours a week are you available for work? Are you legally eligible for employment in the United States? YES NO How did you learn of our organization?Newspaper Ad Agency employee Other Are you willing to work: Evenings Weekends Position applying for: Educational Background School Name / Location Major Yrs of Study/Degree College / Graduate Vo-Tech / Trade High School Others EMPLOYMENT List the last five years employment history, starting with the most recent employer. 1. Company Name: Telephone: Address: , , Dates of Employment: Starting Pay: Ending Pay: Job Title and Describe Work Completed: Reason for leaving: 2. Company Name: Telephone: Address: , , Dates of Employment: Starting Pay: Ending Pay: Job Title and Describe Work Completed: Reason for leaving: 3. Company Name: Telephone: Address: , , Dates of Employment: Starting Pay: Ending Pay: Job Title and Describe Work Completed: Reason for leaving: Was your last name different from your present name during the above listed jobs?YES NO If yes, what was your name? Are you currently employed? YES NO Do you have reliable transportation / the ability to reach multiple clients? YES NO TWO (2) Professional / Personal Reference Check 1. Reference Full Name * Phone * City * State * If Professional Reference: Position Held 2. Reference Full Name * Phone * City * State * If Professional Reference: Position Held GENERAL Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency? YESNO Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full: Are you capable of performing the job set forth in the job description? YESNO If you answered No, which job requirement can you not meet? List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience. CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENTOPERATED I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I, * authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time Signature* Clear Date* -Month -DayYear Date SaveSubmit Should be Empty: There are 2 errors on this page. Please correct them before moving on.See ErrorsDone
