Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Date Available? (required)

Type of employment desired? (required)

Position Applied For (required)

Desired Hourly Rate?

If applicable, list below any other names by which you have been known, which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of assumed name, nickname, etc. (required)

Section 2 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and number of years completed.

Certificate/License (required)

Section 3 - Work Experience:

Current and/or Last Employer (required)

Address: (required)

City: (required)

State: (required)

Zip Code: (required)

Start Date: (required)

End Date: (required)

Position/Title: (required)

Describe Your Responsibilities: (required)

Supervisor's Name/Title: (required)

Supervisor's Phone: (required)

Reason for Leaving: (required)

May we contact? (required)

Yes No

What will this employer say was the reason your employment terminated? (required)

How much notice did you give when resigning? If none, explain. (required)

Previous Employer (required)

Address: (required)

City: (required)

Zip Code: (required)

End Date: (required)

Position/Title: (required)

Describe Your Responsibilities: (required)

Supervisor's Name/Title: (required)

Supervisor's Phone: (required)

Reason For Leaving: (required)

May we contact? (required)

What will this employer say was the reason your employment terminated? (required)

How much notice did you give when resigning? If none, explain. (required)

Section 4 - References; PROFESSIONAL ONLY

First Professional Reference Name: (required)

Company: (required)

Phone: (required)

Second Professional Reference Name: (required)

Company: (required)

Phone: (required)

Section 5 - Letter of Recommendation and Resume

I understand if I am scheduled for an interview, I will be able to provide one professional letter of recommendation and my resume on the day of scheduled interview. (required)

Yes No

Section 6 - Answer the questions to the best of your ability

You are taking care of a patient with Alzheimer's for a few months now. It has been brought to your attention that money is missing from the home, how would you handle this situation? (required)

You are on a 24 hour shift case and the caregiver who was supposed to relieve you is 15 minutes late and has not called yet in regards to their tardiness. What steps would you take to resolve this issue? (required)

You are about to make dinner and the client requests a meal that your are not familiar with preparing. How would you keep your client happy? (required)

Section 7 - Applicant Certification

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside. (required)

Yes No

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. (required)

Yes No

I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company’s policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. (required)

Yes No

If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company’s policies and applicable federal, state, and local law. (required)

Yes No

If employed by the Company, I understand and agree that the Company, to the extent permitted by federal, state, and local law, may exercise its right, without prior warning or notice, to conduct investigations of property (including, but not limited to, files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property. (required)

Yes No

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement. (required)

Yes No

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal. (required)

Yes No

I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state and/or local law. If applicable and allowed by law, I will receive separate written notification regarding the Company’s intent to obtain “consumer reports.” (required)

Yes No

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the abovementioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. (required)

Yes No

I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, I authorize the company to provide truthful information concerning my employment to future employers and hold the company harmless for providing such information. (required)

Yes No

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States. (required)

Yes No

IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL. (required)

Yes No

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature

Uplifting Elderly Home Care LLC Application Form

Personal Information

Section 1 - General Information

Section 2 - Education

Section 3 - Work Experience:

Section 4 - References; PROFESSIONAL ONLY

Section 5 - Letter of Recommendation and Resume

Section 6 - Answer the questions to the best of your ability

Section 7 - Applicant Certification