Job Application Form

Last Name *

First Name *

Middle Initial or Maiden

Home Address

City

State

Zip Code

Number of Years at this Address

Date of Birth:

Social Security Number:

Daytime Phone:

Evening Phone:

Mobile Phone:

Email *

Driver's License Number

Who should be contacted if you are involved in an emergency?

Name:

Relationship:

Address

City:

State:

Zip

Daytime Phone:

Evening Phone:

Position Applied For

Caregiver

Supervisor

Other Administrative

Salary Desired

Who referred you to our company?

Do you have any friends or relatives who work here? If yes, please list here

Have you applied to our company previously?

Yes

No

If yes, when?

Are you at least 18 years old?

Yes

No

How will you get to work?

Have you ever been convicted of a felony?

Yes

No

What hours are you available to work

If you are offered employment, when would you be available to begin work?

If hired, are you able to submit proof that you are legally eligible for employment in the United States?

Yes

No

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?

Yes

No

What reasonable accommodation, if any, would you request?

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment.

Employer Name

City

State

Zip Code

Job Title

Supervisor's Name

From

To

Job Duties

Reason for Leaving

Employer Name

City

State

Zip Code

Job Title

Supervisor's Name

From

To

Job Duties

Reason for Leaving

Employer Name

City

State

Zip Code

Job Title

Supervisor's Name

From

To

Job Duties

Reason for Leaving

Employer Name

City

State

Zip Code

Job Title

Supervisor's Name

From

To

Job Duties

Reason for Leaving

Employer Name

City

State

Zip Code

Job Title

Supervisor's Name

From

To

Job Duties

Reason for Leaving

Employer Name

City

State

Zip Code

Job Title

Supervisor's Name

From

To

Job Duties

Reason for Leaving

College/University Name and Address

Did you receive a degree?

Yes

No

If yes, degree(s) received:

High School/GED Name and Address

Did you receive a degree?

Yes

No

If yes, degree(s) received:

Other Training (graduate, technical, vocational):

Please indicate any current professional licenses or certifications that you hold:

Awards, Honors, Special Achievements:

Military Service:

Yes

No

Branch:

Specialized Training:

List three (3) people NOT RELATED TO YOU who would be willing to provide a reference for you.

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

BACKGROUND INVESTIGATION AUTHORIZATION

I understand that in connection with the application process Americare Incorporated will request a background check (consumer report) on me. My signature authorizes Americare Incorporated, its' employees, representatives and agents to investigate my background and to obtain a consumer report and/or investigative consumer report for client screening purposes. I further authorize, without reservation, any party or agency contacted by Americare Incorporated or its' agents, its' employees, representatives and agents, to furnish information required in connection with the preparation of a consumer report or investigative consumer report.

Applicant Signature: *

Clear

Date Signed:

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize Americare Incorporated to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Director, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Americare Incorporated, except in a specific written contract of employment signed on behalf of the organization by its Director, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Signature: *

Clear

Date

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