Helping Hearts LLC

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:
Salary:
Type of Work:
Reason for Leaving:
Employer 2:
Address/City:
From Date:
To Date:
Supervisor:
Phone:
Salary:
Type of Work:
Reason for Leaving:
Employer 3:
Address/City:
From Date:
To Date:
Supervisor:
Phone:
Salary:
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?: 21
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

All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired. I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment. I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, you will be notified.) I understand that a job offer may be contingent upon the satisfactory results of a state criminal background check and a review of various state and federal registries applicable to home care workers.

Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company's unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed written document. If employed I agree to abide by all the company's rules and regulations and any changes to them. We have a policy of no smoking on the premises.

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