Home Helper Application: Step 2

Position for which you are applying:

Caregiver Office Staff

Contact Information

First Name: Last Name:
Address: City:
State: Zip:

Best phone number to reach you:

Home phone: Cell phone:

Additional Information

Acceptable salary range requesting?
How many hours of work are you interested working week? hours per week

Please list the hours available for each day below to equal hours listed above. Include "am" or "pm"

	Saturday	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday
From (time)
To (time)

In order to evaluate your application, we are relying on your availability as stated above to be accurate.

Do you have any disabilities that may limit your ability to perform the work for which you are applying?

Yes No

Have you ever worked for Home Helpers?

Yes No

If yes,
Dates:
Location:
Supervisor:

Education (minimum required is High School Diploma or General Equivalency Diploma; GED)

Type of School	Name and Address of School	Diploma/Degree
High School or GED

College

List any additional or special education, training, skills or machines operated.

Employment History Begin with most recent employment for the past 5 years.

Dates From: To:
Company Name: City: State:
Titles: Duties:
Supervisor's Name: Phone:
Reason for Leaving:

Dates From: To:
Company Name: City: State:
Titles: Duties:
Supervisor's Name: Phone:
Reason for Leaving:

Dates From: To:
Company Name: City: State:
Titles: Duties:
Supervisor's Name: Phone:
Reason for Leaving:

If time elapsed between positions, please explain

Character References (Must provide four non-family member references)

Name: Phone: Relationship:
Name: Phone: Relationship:
Name: Phone: Relationship:
Name: Phone: Relationship:

How were you referred to Home Helpers?

PLEASE READ CAREFULLY

U.S. employment eligibility verification
I understand that, if hired, I will be required to offer for examination documents proving that I am a United States citizen or an alien currently authorized to work in the United States. I also understand that my continued employment is contingent upon my providing necessary documentation within prescribed time frames as required under law.

Consent to verify applicant information and make other inquiries
I understand that the company may investigate my work and personal history and verify all data given on this application, on related papers, and in interviews, and I authorize your company to investigate and verify such. Inquiries may include information as to my character, general reputation, and personal characteristics, and I consent to the conduct of such inquiries and to the company's consideration of employment as to any statements of references or former employers that are given in response to such inquiries. I authorize all individuals, schools, and employers named therein, except as specifically limited on this application, to provide information requested about me, and I release them from liability for damages in providing this information.

Medical/Physical examinations and drug testing
I understand that an offer of employment is subject to the results of any pre-employment drug testing, if any is required. I also understand and acknowledge that, as a part of the hiring process and throughout my employment, if hired, I may be required to submit to medical/physical examinations at the employer's discretion and expense.

Direct Deposit of Pay
I understand that as a condition of employment that I must provide Home Helpers with my bank's routing number(s) and account number(s) to which my pay may be directly deposited. This may be accomplished by providing Home Helpers with a letter from your bank(s) that gives the proper routing and account numbers, or by providing Home Helpers with a voided check.

Offers of employment
I understand and agree that no manager, representative, agent or employee of the company, other than the President, has now or has had in the past any authority to enter into any agreement for employment for any specified period of time or to make any agreement which is contrary to or a modification of the company's standard Employee Agreement, and that any such contrary or modified agreement or representation must be in writing and signed by both myself and the President of the company in order to be effective.

Application is true and complete
I hereby certify that to the best of my knowledge that the answers given in this Application are true and complete without qualifications. I also understand that an omission or falsification may disqualify me from consideration for employment or if hired may be grounds for immediate dismissal.

I acknowledge the information provided is true