New HR Application Form

Blessed Hands Home Care LLC Application For Employment

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, national origin, ancestry, veteran status, medical condition, sexual orientation, marital status or any other characteristic protected by applicable state or federal civil rights laws.

Section One: Demographics

Legal Name:

Physical Address:

Mailing Address if different from above:

Ten Digit Phone Number:

Date of Birth:

Do you have a valid Driver’s License?

Yes

Can you provide proof of current auto insurance and registration?

Yes

Section Two: Background, Certifications & Former Employment ( Criminal Background)

Blessed Hands Home Care IS REQUIRED BY LAW TO RUN A BACKGROUND CHECK ON ALL POTENTIAL EMPLOYEES. PLEASE PROVIDE AS MUCH DETAILS AS POSSIBLE/NEEDED IN THIS SECTION.

Have you ever been convicted of a criminal offense?

Yes

If yes, please state the nature of the crime(s), when and where you were convicted and the disposition of the case else fill "NO"

Driver's License Number

Education

High School:

College:

Vocational or Post Secondary School:

Do you currently hold any professional licenses?

Yes

Please describe the nature of your license:

Date Received License:

Institution that you studied at and graduated from:

Are you a Certified Nursing Assistant?

Yes

If yes, are you actively registered in State?

Date Received Certification:

School Received Certification From:

Are you a certified Personal Support Specialist?

Yes

If yes, are you actively registered In State?

Date Received Certification:

School Received Certification From:

Any other training, certificates, courses, experience, skills and/or qualifications?

Availability:

Please list days and times you can work:

Any days and times not available to work?

Can you be called at the last minute for emergency assignments?

Desired Salary:

Employment History:

Other name(s) under which employment may be verified:

(Employer One)

Name of Business:

Address:

Date employed:

Reason for leaving:

Name of Supervisor:

Phone Number:

Permission to contact?

Yes

(Employer Two)

Name of Business:

Address:

Date employed:

Reason for leaving:

Name of Supervisor:

Phone Number:

Permission to contact?

Yes

(Employer Three)

Name of Business:

Address:

Date employed:

Reason for leaving:

Name of Supervisor:

Phone Number:

Permission to contact?

Yes

Business References:

(give the names of three persons not related to you and whom have known you for at least one year.)

References One

Name, Relationship, Years Known and Phone Number:

References Two

Name, Relationship, Years Known and Phone Number:

References Three

Name, Relationship, Years Known and Phone Number:

CERTIFICATION AND RELEASE:

I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.

I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records.

I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment

Enter name as signature

Date