Anodyne Homemaker Services

Employment Application

The BLUE labels indicate required information.
Applicant Information
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
E-mail:
Cell:
Best time to call:
Desired Position:
If Other:
Experience
Do you have experience working in home care?
If so, was experience gained working for an agency? (List job in prior employment)
If so, was experience gained working for an individual? (List name, address, phone in prior employment)
Availability
Please indicate the days and times you are available to work.
Mon:
Time:
Tues:
Time:
Wed:
Time:
Thurs:
Time:
Fri:
Time:
Sat:
Time:
Sun:
Time:
Employment History
Please list chronologically, beginning with most recent experience.
Employer 1:
Address/City:
From Date:
To Date:
Supervisor:
Phone:
Type of Work:
Reason for Leaving:
Employer 2:
Address/City:
From Date:
To Date:
Supervisor:
Phone:
Type of Work:
Reason for Leaving:
Employer 3:
Address/City:
From Date:
To Date:
Supervisor:
Phone:
Type of Work:
Reason for Leaving:
Education
High School
Last Year Completed
Diploma/Degree
College/University
Last Year Completed
Major
Degree
Business or Trade School
Years Completed
Subject Studied
Diploma/Degree
Hospice
Dementia
Incontinence
Transfer Heavy Client
Gait Belt
Hoyer Lift
Other Training
Homemaking
Personal Care Homemaking
Companion
Chore
Certifications
Home Health Aide
Supportive Home Care Aide
Medical Assistant
Human Service Provider/Mental Health Worker
Licenses
Certified Nursing Assistance
Licensed Practical Nurse
Registered Nurse
Personal Information
Are you legally authorized to work in the U.S.?:
(If hired, you will be required to provide proof of work authorization.)
Are you at least this many years of age?: 18
Briefly describe skills you may have that you acquired in other employment or armed forces:
Do you have any other skills you wish to mention?:
Are you presently employed?:
If so, may we contact your present employer?:
If hired, when would you be available?:
Employment References
List individuals familiar with your job qualifications (No relatives or personal friends).
1) Name of Reference:
Occupation:
Address:
City/State/Zip:
Phone:
Email:
Relationship:
How long known:
2) Name of Reference:
Occupation:
Address:
City/State/Zip:
Phone:
Email:
Relationship:
How long known:
How Were You Referred To This Job:
Please read carefully before submitting your application

Anodyne Medical Services Corp is committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religion, creed, national origin, ethnicity, ancestry, sex, age, disability, genetic information/genetics, gender identity/expression, marital status, veteran’s status, military status, sexual orientation, or any other characteristic protected by law.

Please read the following statements; they constitute the conditions under which you would be employed by Anodyne Medical Services Corp (the Company) should you be accepted for employment.

I certify that all information that I have provided on this application is true and complete to the best of my knowledge. I understand that falsification, misrepresentation or omission of facts called for in this application may result in denial of employment or immediate dismissal.

I understand that if I am employed by Anodyne Medical Services Corp (the Company), my employment is for no definite term and that I can be terminated at any time with or without notice and with or without cause. I further understand that no verbal promises or guarantees are binding on the Company and that no one, other than the President of the Company, has authority to enter into an agreement for employment contrary to the above, and that any such agreement must be in writing. If employed, I agree to abide by all of the Company’s rules and regulations, and any changes thereto.

I understand that a job offer may be contingent upon the satisfactory results of Criminal Offender Record Information (CORI) check, Office of Inspector General (OIG) check, Department of Public Health Massachusetts Nurse Aide Registry check and receipt of medical clearance.

I give the Company permission to investigate all pertinent information concerning my application in order to determine my qualifications for employment. I understand that any offer of employment may be rescinded if the results of the investigation are unacceptable to the Company.

Massachusetts General Laws c.149 S19B requires that the following statement be included on employment applications: “It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment. An employer who violates this law shall be subject to criminal penalties and civil liability.”

Massachusetts General Laws c. 151B defines “genetic information” as any written record or explanation of a genetic test of a person’s family history with regard to the presence, absence or variation of a gene. A genetic test is broadly defined as “any test of DNA, RNA, mitochondrial DNA, chromosome or proteins for the purpose of identifying genes or genetic abnormalities.” The law expressly excludes drug and alcohol tests from this definition, meaning that employers may continue to conduct such tests in accordance with existing legal requirements.

These new statutory provisions specifically prohibit employers from (1) terminating or refusing to hire individuals on the basis of genetic information; (2) requesting genetic information concerning employees, applicants or their family members; (3) attempting to induce individuals to undergo genetic tests or otherwise disclose genetic information; (4) using genetic information in any way that affects the terms and conditions of an individual’s employment; or (5) seeking, receiving or maintaining genetic information for any non-medical purpose.

 Check this box to certify that you have read and accept the above statement.
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