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Apply to join our team!
click here for application form and requirements
Employment Application
All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.
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Date
*
Name
*
First
Middle
Last
Email
*
Street Address
*
City, State, Zip Code
*
Personal Phone
*
Home Phone
Emergency Contact (person not living with you)
Have you ever applied for employment with this agency?
Yes
No
How many hours a week are you available for work?
Are you legally eligible for employment in the United States?
Yes
No
How did you learn of our organization?
Online Ad
Agency Employee
Other
Are you willing to work:
Evenings?
Weekends?
Position applying for:
Education
Employment
List the last five years employment history, starting with the most recent employer.
Was your last name different from your present name during the above listed jobs?
Yes
No
If yes, what was your name?
Are you currently employed?
Yes
No
Do you have reliable transportation?
Yes
No
Professional References
List three people who can furnish information about job performance.
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
Yes
No
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:
Are you capable of performing the job set forth in the job description?
Yes
No
If no, which job requirement can you not meet?
Credentials/Specialized Skills & Qualifications/Equipment Operated
Please Sign here:
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.
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