Draft Job Application - True Help Home Care

Job Application

Independent Contractor Application

Last Name:

First Name:

Middle Name:

Home Number:

Cellular Number:

Other Number:

Social Security Number:

Email:

Address:

City:

State:

Zip Code:

Please select the position you are applying for:

How were you referfed to us?

Date Avaiilable for work?

Anticipated Wage?

Please indicate your availability or interest below

Work Status:

Full Time (32 hours per week average) Part Time (less than 32 hours per week average)

Hours Available:

Education

High School Diploma Associate Bachelors Masters

Name of High School:

Degree:

Year Graduated:

Name of College or Undergraduate Education/School:

Degree:

Year Graduated:

Name of College or Undergraduate Education/School:

Degree:

Year Graduated:

License / Certifications / Examinations

Type of License:

State of License:

Expiration Date:

License Number:

Any restriction or pending action on license?

Yes No

CPR Expiration:

Last Physical Exam:

Last TB / Chest X Ray:

Are you legally authorized to work in the USA?

Yes No

If you become an employee of this Agency you will be required to provide documentation proving you eligibility to work on the USA.

Have you ever been convicted of a crime in the past 5 years, barring employment in the Home Care and community support Agency:

Yes No

If yes, state the basis for each conviction and date of the conviction.

Have you ever been employed by this Agency?

Yes No

If yes, give date

In case of emergency , notify:

Phone:

Relationship:

In case of emergency , notify:

Phone:

Relationship:

Personal References (Please furnish three references with complete address. Do not list former emploters or relatives. The individuals you list shoud have know you for at least one year.)

Name:

Address:

Phone Number:

Business:

Years Known:

Name:

Address:

Phone Number:

Business:

Years Known:

Name:

Address:

Phone Number:

Business:

Years Known:

Work History

Company Name (Present or most recent employer)

From:

To:

Company Address, City, State:

Wages:

Describe your job responsibilities and duties:

Supervisor's Name:

Phone Number:

May We Contact?

Reason for Leaving?

Company Name (Present or most recent employer)

From:

To:

Company Address, City, State:

Wages:

Describe your job responsibilities and duties:

Supervisor's Name:

Phone Number:

May We Contact?

Reason for Leaving?

Company Name (Present or most recent employer)

From:

To:

Company Address, City, State:

Wages:

Describe your job responsibilities and duties:

Supervisor's Name:

Phone Number:

May We Contact?

Reason for Leaving?

Company Name (Present or most recent employer)

From:

To:

Company Address, City, State:

Wages:

Describe your job responsibilities and duties:

Supervisor's Name:

Phone Number:

May We Contact?

Reason for Leaving?

I agree, that the information that I have given is true and accurate to the best of my knowledge.

I hereby acknowledge that I have read, understand and agree to statements stablished in the Application Authorization Page.

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