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Application Form (1)

APPLICATION FOR EMPLOYMENT

APPLICANT INFORMATION

First Name(Required)

Middle Name(Required)

Last Name(Required)

DOB:(Required)

SS#(Required)

Date:(Required)

Mailing Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Home Phone:(Required)

Cell Phone:(Required)

Marital Status:(Required)

Date of Birth:(Required)

Desired Salary:(Required)

Employment Desired(Required)

Position Applied For(Required)

Gender(Required)

MALE

FEMALE

Are you a citizen of the United Stated?(Required)

YES

Are you authorized to work in the U.S.?(Required)

YES

Have you ever worked for this company, if so when?(Required)

Are you related to anyone who works this company?(Required)

YES

Have you ever been convicted of a felony, if so when?(Required)

Do you have a current driver’s license?(Required)

YES

Have you had any accidents during past three year, if so how many?(Required)

PERSON TO CONTACT IN CASE OF EMERGENCY:(Required)

Relationship:(Required)

Address:(Required)

Contact No.:(Required)

ATTACHED RESUME

Max. file size: 64 MB.

EDUCATION

High School:(Required)

Address:(Required)

From:(Required)

To:(Required)

Did you graduate?(Required)

YES

Did you graduate?(DEGREE)(Required)

Diploma

GED

College:(Required)

Address:(Required)

From:(Required)

To:(Required)

Did you graduate?(Required)

YES

Degree:(Required)

Major:(Required)

Other:(Required)

Address:(Required)

From:(Required)

To:(Required)

Did you graduate?(Required)

YES

Degree:(Required)

Address:(Required)

REFERENCES

PLEASE LIST THREE PROFESSIONAL REFERENCES NO RELATIVES

Full name:(Required)

Relationship:(Required)

Position:(Required)

Phone:(Required)

Address:(Required)

Full name:(Required)

Relationship:(Required)

Position:(Required)

Phone:(Required)

Address:(Required)

Full name:(Required)

Relationship:(Required)

Position:(Required)

Phone:(Required)

Address:(Required)

PREVIOUS EMPLOYMENT

Company:(Required)

Phone:(Required)

Address:(Required)

City:(Required)

State:(Required)

Zip Code:(Required)

Supervisor:(Required)

Job title:(Required)

Starting salary:(Required)

Ending salary:(Required)

Responsibilities:(Required)

From:(Required)

To:(Required)

Reason for leaving:(Required)

May we contact your previous supervisor for a reference?(Required)

Yes

Company:(Required)

Phone:(Required)

Address:(Required)

City:(Required)

State:(Required)

Zip Code:(Required)

Supervisor:(Required)

Job title:(Required)

Starting salary:(Required)

Ending salary:(Required)

Responsibilities:(Required)

From:(Required)

To:(Required)

Reason for leaving:(Required)

May we contact your previous supervisor for a reference?(Required)

Yes

Company:(Required)

Phone:(Required)

Address:(Required)

City:(Required)

State:(Required)

Zip Code:(Required)

Supervisor:(Required)

Responsibilities:(Required)

From:(Required)

To:(Required)

Reason for leaving:(Required)

May we contact your previous supervisor for a reference?(Required)

Yes

MILITARY SERVICE

Branch:(Required)

From:(Required)

To:(Required)

Rank at discharge:(Required)

Type of discharge:(Required)

If other than honorable, explain:(Required)

PLEASE READ CAREFULLY APPLICATION FORM WAIVER

In exchange for the consideration of my job application by AT HOME CARE, inc. (hereinafter called “the company”), I agree that: neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the company, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the president/general manager of the company. Both the undersigned and the company may end the employment relationship at any time, without specified notice or reason. If employed, i understand that the company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the company permission to contact schools, previous employers, references, and others, and hereby release the company from any liability as a result of such contact.

I also understand that (1) the company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy.

I further understand that my employment with the company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the company is terminable at will for any reason by either party.

This company is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this company depends solely on your qualifications.

Signature:(Required)

Date:(Required)

OFFICE USE ONLY

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Date orientated:

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Hired date:

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Position given:

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Start date:

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Supervisor Signature:

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Date:

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Human Resource Signature:

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Date filed:

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Staff Development Signature:

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Date filed:

REFERENCE INQUIRY

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PERSONNEL DIRECTOR/OFFICE MANAGER

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SUPERVISOR

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FAX #:

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ATTN:

NAME OF APPLICANT(Required)

SOCIAL SECURITY #(Required)

D.O.B.(Required)

AUTHORIZATION

I,(Required)

hereby authorize At Home Care, Inc. to request verification of statement made by me on my employment application, and any other job related information. I also give permission to the Company addressed above to release information requested by At Home Care, Inc. I will not hold At Home Care, Inc. or the releasing company liable for statements made.

INFORMATION BELOW THIS LINE FOR OFFICE USE ONLY

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DATES OF EMPLOYMENT

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JOB TITLE

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REASON FOR LEAVING

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Is the above information correct?

Yes

If not, please make corrections.

Please select the appropriate answer for the following categories:

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Attendance

Above Average

Average

Below Average

Unsatisfactory

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Attendance

Above Average

Average

Below Average

Unsatisfactory

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Honesty

Above Average

Average

Below Average

Unsatisfactory

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Cooperation

Above Average

Average

Below Average

Unsatisfactory

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Dependability

Above Average

Average

Below Average

Unsatisfactory

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Initiative

Above Average

Average

Below Average

Unsatisfactory

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Courtesy

Above Average

Average

Below Average

Unsatisfactory

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Quantity of Work

Above Average

Average

Below Average

Unsatisfactory

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Ability to Learn

Above Average

Average

Below Average

Unsatisfactory

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Trustworthiness

Above Average

Average

Below Average

Unsatisfactory

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Would you rehire this applicant?

Yes

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If not, please explain.

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Would you recommend that we employ this applicant?

Yes

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If not, please explain.

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NAME AND JOB TITLE OF PERSON PROVIDING INFORMATION

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