Employment Application - Caring for You in the Comfort of Home

Employment

Caregivers in Huntsville, Alabama

Fill and submit the form below with the correct information.

Personal Information

Date *

Name (Last Name First) *

Date of Birth *

Age *

Race

Email *

Social Security No. *

Present Address *

City *

State *

Zip Code *

Permanent Address

City

State

Zip Code

Phone No. *

Secondary Phone No.

Referred By

Employment Desired

Position *

Date You Can Start *

Salary Desired ($) *

Are you employed now? * YesNo

Are you legally authorized to work in the U.S.? * YesNo

Ever applied to this company before? * YesNo

Ever worked for this company before? * YesNo

Education History

High School

Name of School *

Location *

Years Attended *

Did you graduate? * YesNo

Subjects Studied *

College / University

Name of School *

Location *

Years Attended *

Did you graduate? * YesNo

Subjects Studied *

Trade, Business, or Correspondence School

Name of School

Location

Years Attended

Did you graduate? YesNo

Subjects Studied

General Information

Subject of Special Study / Research Work

Special Training, Certifications, Licenses

Language Spoken

Military Service Record

Have you ever served in the U.S. Armed Forces? YesNo

Branch of Service

Discharge Date

Rank

Former Employers (List below last three employers, starting with most recent)

Present or Last Employer

Name of Present or Last Employer *

Address *

City *

State

Zip Code *

Starting Date *

Leaving Date *

Job Title *

Weekly Starting Salary ($) *

Weekly Final Salary ($) *

May we contact your supervisor? * YesNo

Name of Supervisor *

Title *

Phone *

Description of Work *

Reason for Leaving *

Previous Employer 2

Name of Previous Employer

Address

City

State

Zip Code

Starting Date

Leaving Date

Job Title

Weekly Starting Salary ($)

Weekly Final Salary ($)

May we contact your supervisor? YesNo

Name of Supervisor

Title

Phone

Description of Work

Reason for Leaving

Previous Employer 3

Name of Previous Employer

Address

City

State

Zip Code

Starting Date

Leaving Date

Job Title

Weekly Starting Salary ($)

Weekly Final Salary ($)

May we contact your supervisor? YesNo

Name of Supervisor

Title

Phone

Description of Work

Reason for Leaving

Personal Reference

Name

Phone

Address

Business Reference

Name

Address

Business

Phone

Name

Address

Business

Phone

Special Purpose Questions

DO NOT ANSWER ANY OF THE QUESTIONS IN THIS BOX UNLESS THE EMPLOYER HAS CHECKED THE BOX PRECEDING A QUESTION, THEREBY INDICATING THAT THE INFORMATION IS REQUIRED FOR A BONAFIDE OCCUPATIONAL QUALIFICATION, OR DICTATED BY NATIONAL SECURITY LAWS, OR IS NEEDED FOR OTHER LEGALLY PERMISSIBLE REASONS.

Height

Feet

Inches

Weight

Lbs.

Are you a US citizen? YesNo

Have you been convicted of a? Within the last 5 years FelonyMisdemeanor YesNo

Describe

You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied.

I understand and agree that I may be required to take one or more: physical examination; drug test; lie detector test; as a condition of hiring or continued employment. I agree to consent to take such test(s) at such time as designated by the Company and to release the Company, its directors, officers, agents or employees from any claim arising in connection with the use of such test(s).

YesNo

I have been advised that lie detector tests, as a condition of hiring or continued employment, are prohibited by law.

YesNo

Are you able to perform each of the following job functions with or without an accommodation?

Are you able to lift 50lbs. or more? YesNo

If you can perform the function with an accommodation, explain how you would perform the task, and with what accommodation?

Do you have experience using a Hoyer lift? YesNo

If you can perform the function with an accommodation, explain how you would perform the task, and with what accommodation?

Do you have caregiving experience? YesNo

If you can perform the function with an accommodation, explain how you would perform the task, and with what accommodation?

Were you ever seriously injured? YesNo

Authorization

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 investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

Date *