Amazing Grace Home Health Care

EMPLOYMENT APPLICATION

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

Please read "Applicant Note” below.
Complete all pages of this application.
Print clearly. Incomplete or illegible applications may not be accepted.
If more space is needed to complete any question, use comments section on the back.
Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us at Amazing Grace HHC. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

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PERSONAL INFORMATION

Today’s Date:

Positions(s) Applied For:

Name:

Last:

First:

Middle:

Current Address:

Street:

City:

State:

Zip Code:

Previous Address:

Street:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Alternate Phone:

Email Address:

Please check your email address for errors

Emergency Contact(s):

Name:

Phone:

Name:

Phone:

Valid Driver’s License #:

State Issued:

Exp. Date

Make & Model of Vehicle:

Year of vehicle:

Auto In Co:

Policy #

Exp Date:

Have you ever submitted an application here before? Yes No

If yes, when?

Have you ever been employed here before? Yes No

If yes, when?

How did you hear about our Home Instead Senior Care franchise?

Have you have been given a copy of the job description for the position for which you have applied to review. Yes No

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? Yes No

Why are you interested in employment with us?

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

What date are you available to begin work?

Please complete all areas of availability:

Mornings

Afternoons

Evenings

Overnight

Weekdays

Weekends

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

Monday

From

Shift

Tuesday

From

Shift

Wednesday

From

Shift

Thursday

From

Shift

Friday

From

Shift

Saturday

From

Shift

Sunday

From

Shift

PREFERENCES

Please indicate all areas of the city in which you are willing to work:

Indian River County

St. Luice County

Brevard County

Please indicate the types of services which you are willing to provide:

Companionship

Housekeeping (dust/vacuum)

Errands/Shopping/Transportation*

Meal Preparation

Laundry/Ironing

Personal Care

Activities (games/crafts)

Medication Reminders

Dementia/Alzheimer’s Care

*In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required.

Are you willing to provide service to a client with a pet? Yes No

If yes, which ones:

Cats

Dogs

Are you willing to provide service to a client that smokes? Yes No

JOB RELATED SKILLS

Describe any training or life skills you have that apply to caring for a senior:

Describe any work history you have that would apply to caring for a senior:

What do you like (or think you would like) most about working with older adults?

What do you like (or think you would like) least about working with older adults?

What personal rewards do you get from working with seniors?

Education

Please circle highest grade completed

Grade School 6 7 8

High School 9 10 11 12

College 13 14 15 16 16+

High School

School Name

City/State

Major/Subject

# Years Attended

Graduate Yes No

Vocational/Technical

School Name

City/State

Major/Subject

# Years Attended

Graduate Yes No

Vocational/Technical

School Name

City/State

Major/Subject

# Years Attended

Graduate Yes No

Work History

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Are you currently working for this employer? Yes No

If yes, may we contact? Yes No

MOST RECENT EMPLOYER

Company

City

State

Phone Number

Dates Employed

From

Job Title

Supervisor's Name

Duties

Salary

Per Hour Week Month

Reason For Leaving

SECOND MOST RECENT EMPLOYER

Company

City

State

Phone Number

Dates Employed

From

Job Title

Supervisor's Name

Duties

Salary

Per Hour Week Month

Reason For Leaving

THIRD MOST RECENT EMPLOYER

Company

City

State

Phone Number

Dates Employed

From

Job Title

Supervisor's Name

Duties

Salary

Per Hour Week Month

Reason For Leaving

SECURITY

*******Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.

As a condition of employment all employees must be “Bondable”& “Insurable”. Are you at least 19 years of age? Yes No

List states and counties of residence for the past seven years:

Have you had any moving traffic violations? Yes No

If yes, please describe

Have you been charged/convicted of a felony and/or misdemeanor/or served time Yes No

If yes, please describe:

Incident

City/State

Charge

Incident

City/State

Charge

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? Yes No

REFERENCES (Do not include relatives)

Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all three references, you will be asked to provide additional references.

Reference 1

Full Name

Home Phone

Best time to call

Work Phone

Best time to call

Relationship

Number of Years Known

Reference 2

Full Name

Home Phone

Best time to call

Work Phone

Best time to call

Relationship

Number of Years Known

Reference 3

Full Name

Home Phone

Best time to call

Work Phone

Best time to call

Relationship

Number of Years Known

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one (1) 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 misrepresentations of facts 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 consumer-reporting bureaus, to verify any of this 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 release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Amazing Grace HHC, and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

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Date

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772.501.0507

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Amazing Grace Home Health Care

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

AVAILABILITY

PREFERENCES

JOB RELATED SKILLS

Education

Work History

SECURITY

REFERENCES (Do not include relatives)