Persons who can furnish information about job performance or personal information about you.
1)
List all states in which licensed giving registration and expiration date. *
2)
Summarize special job-related skills and qualification acquired from employment or other experience. *
1)
How many hours a week are you available for work? *
2)
Are you legally eligible for employment in the United States? *
3)
Are you willing to work *
4)
Emergency contact (person not living with you) *
5)
Are you currently employed? *
6)
Do you have reliable transportation? *
7)
Have you ever been convicted of a crime in the past 5 years, barring employment in a home care community and support agency? If yes, please explain: *
8)
Are you capable of performing the job set forth in the job description? *
9)
If no was your answer in the last question, which job requirement can you not meet? *
PLEASE READ ALL STATEMENTS BELOW BEFORE SIGNING THIS APPLICATION:
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 any and 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.
This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.
This Agency will perform a criminal history check including the National Sex Offender registry for any direct care position, or a position that has access to patient/client records. By signing this application, I acknowledge and agree to the Agency conducting a criminal history check if I am offered employment by 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 of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.
I acknowledge that I have been provided with a copy of the Consumer/Patient Bill of Rights, if applicable and required by state law.
Employee Signature: __________________
Date:
September 17, 2025
