Employment

Welcome, Caregiver Applicant,

Thank you for your consideration of HomeCare Instead for employment. We are looking for caring individuals who find fulfillment in helping people. If you believe that this would be a rewarding career path, have the physical ability and strength needed, and would be able to provide reliable transportation when necessary, please proceed to the online application below.

New Employement Form

Personal

Name

Last name - First - Middle

Date

Home Phone

Street Address

City

State

Zip code

How many years have you lived there? Example: 1 year, 6 months

Business Phone

End Section

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Are you willing to work?

Evenings

Weekends

Position applying for

College

Name

Location

Course of Study

Years

End Section

Vo-Tech or Trade

Name

Location

Course of Study

Years

End Section

High School

Name

Location

Course of Study

Years

End Section

Other

Name

Location

Course of Study

Years

End Section

Employment

List the last five years of employment history, starting with the most recent employer.

1

Company Name

Telephone

Address

Dates of Employment

From

Starting Pay

Job Title and Describe your work

Reason for leaving

End Section

2

Company Name

Telephone

Address

Dates of Employment

From

Starting Pay

Job Title and Describe your work

Reason for leaving

End Section

3

Company Name

Telephone

Address

Dates of Employment

From

Starting Pay

Job Title and Describe your work

Reason for leaving

End Section

Application For Employment

Was your last name different from your present name during the above listed jobs?

Yes

what was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

End Section

Professional References

Persons who can furnish information about job performance

1

Name

Telephone

Fax

Address

End Section

2

Name

Telephone

Fax

Address

End Section

3

Name

Telephone

Fax

Address

End Section

General

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

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?

Yes

which job requirement can you not meet?

End Section

Application For Employment

Credentials/Specialized Skills & Qualification/Equipment Operated
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

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.

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.

Date

Signature

End Section

Applicant Reference Check (1)

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant

Name

Date of Application

Previous Employer

Contact Person

Address

Phone

Fax

I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

Applicant’s Signature

Date

To be completed by previous employer

Date of employment

From

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay

weekly/biweekly/salary

Additional comments

(training/skills)

Reference check performed by

End Section

Applicant Reference Check (2)

Name

Date of Application

Previous Employer

Contact Person

Address

Phone

Fax

Applicant’s Signature

Date

To be completed by previous employer

Date of employment

From

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay

weekly/biweekly/salary

Additional comments

(training/skills)

Reference check performed by

End Section

Employee Emergency Contact Information

Employee Name

Home Phone

Cell Phone

Next of kin

Phone

Relationship

Address

In case of emergency, please contact

Name

Phone

Relationship

Address

Please notify this Agency immediately if any of the emergency contact information changes

LICENSE COPY/VERIFICATIONS –SEE PERSONNEL POLICIES
DIPLOMA/DEGREE/CERTIFICATE/TRANSCRIPT
SOCIAL SECURITY CARD
CPR CARD
DRIVER’S LICENSE
AUTO INSURANCE

File Upload

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Health Statement

I hereby attest that the state of my health is such that it will enable me to perform the duties of a health care professional. I further specifically attest that I am free of any and all potentially contagious diseases.

Applicant Name

Date

End Section

Hepatitis Vaccine Requirement

I acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself. It is my decision to:

Request that I receive the Hepatitis vaccine

Refuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to me.

Provide written proof of immunity

Provide written proof of previous vaccination

Provide written proof of medical contraindication

Signature

Date

End Section

TB Targeted Medical Questionnaire Form

To be completed by employee

Name

Have you ever had a positive TB skin test or history of TB infection?

Yes

End Section

Please answer the following

Have you ever had the BCG vaccine?

Yes

Do you have prolonged or recurrent fever?

Yes

Have you recently lost weight?

Yes

Do you have a chronic cough?

Yes

Do you cough up blood?

Yes

Do you have sweating at night?

Yes

End Section

Message

Resume Upload

Employee Signature

Date

Radio Buttons

Option 1

Option 2

Your Loved Ones are in Good Hands with
HomeCare Instead

Qualified Home Care in City name, State name

Employment

Personal

Education

College

Vo-Tech or Trade

High School

Other

Employment

1

Dates of Employment

2

Dates of Employment

3

Dates of Employment

Application For Employment

Professional References

1

2

3

General

Application For Employment

Applicant Reference Check (1)

To be completed by previous employer

Applicant Reference Check (2)

To be completed by previous employer

Employee Emergency Contact Information

Health Statement

Hepatitis Vaccine Requirement

TB Targeted Medical Questionnaire Form

Please answer the following