Join Our Home Care Team If you are human, leave this field blank. First Name * Middle Name Last Name * Email Address Street Address * City * State * Zip Code * Phone Number Alternative Phone Number Have you ever worked under another name? Yes No If yes, what name? Are you legally entitled to work in the United States without corporate sponsorship? Yes No Are you over the age of 18? Yes No Have you ever applied for a position with Alternative Home Care? Yes No If yes, when and what position? Have you ever worked for Alternative Home Care? Yes No If yes, when and what position? How were you referred to Alternative Home Care? Name the position for which you are applying: Full Time Part Time PRN Expected hourly salary Is there anything that would prevent you from performing in a reasonable and safe manner the essential functions of the position for which you are applying? Yes No If yes, explain: Are there any other positions for which you would like to be considered? Yes No If yes, name them: Have you ever been convicted of a crime? Yes No If yes, state the nature of the offense, when and where it happened, and its disposition: Note: A conviction record will not necessarily be a bar to employment. This information will be used only for job-related purposes and only to the extent permitted by law. If you application is considered favorable, on what date can you begin work? Employment Record Employed From: Employed To: Employer Name, Address & Phone Number May we contact this employer? Yes No Job Title Supervisor Starting Salary Ending Salary Reason for Leaving Add Another + Employed From: Employed To: Employer Name, Address & Phone Number May we contact this employer? Yes No Job Title Supervisor Starting Salary Ending Salary Reason for Leaving Add Another + Employed From: Employed To: Employer Name, Address & Phone Number May we contact this employer? Yes No Job Title Supervisor Starting Salary Ending Salary Reason for Leaving Education Highschool--------------------- Name and Address Years Attended Degree Completed Major Area of Study College--------------------- Name and Address Years Attended Degree Completed Major Area of Study College--------------------- Name and Address Years Attended Degree Completed Major Area of Study Other--------------------- Name and Address Years Attended Degree Completed Major Area of Study Professional Certifications Please list type of certification, state, number, and the expiration. Professional References Please list up to 3 professional references, and a contact phone number for each. Preemployment Statement Please read the statement below and check that you agree. 1. The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews can be justification for refusal to consider my application further or termination from Alternative Home Care if employed. 2. Any offer of employment that I may receive from Alternative Home Care is contingent upon my successful completion of any applicable pre-placement examination(s). 3. As a condition of employment, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that if employed, I may be required to submit to an alcohol and/or drug screening as set forth in Alternative Hoome Care’s Substance Abuse Policy. 4. In processing my application for employment, Alternative Home Care may verify all the information provided by me, or may procure or have prepared a consumer or an investigative consumer report for this purpose concerning my prior employment, military record, education, character, personal characteristics and criminal record. I understand that upon written request to Alternative Home Care, I will be informed of whether an investigative consumer report was requested and will be given full information as to the nature and scope of this investigation. 5. I am authorizing and requesting that all of my present and former employers furnish information about my employment record, including a statement of the reason for termination of my employment, work performance, abilities and other qualities pertinent to my qualifications for employment. I hereby release them from any and all liability for damages arising from furnishing the requested information. 6. In consideration of my employment, I will comply with the policies, rules, regulations and procedures of Alternative Home Care and understand that my employment and compensation can be terminated with or without cause or notice at any time at the option of either Alternative Home Care or myself. Agreement * I agree to the above statements. This application will remain in active status for 90 days from the date of submission. If you want your application to remain in active status after that time, you must reapply in person.