Join Our Team | Immediate Homecare & Hospice

Application for Employment

Position Applying for:

Are you currently bound by any contract or agreement that would legally prevent you from being employed with us?

Yes

Personal

Last Name

First Name

Middle Name

Date

Address

Country

Home Telephone

City

State

Zip

Cell Phone

Have you ever applied for employment with us?

Yes

If yes:

Social Security #

Position Desired

Pay Expected

Apart from absence for religious observance, are you available for full-time work?

Yes

If not, what hours can you work?

Will you work overtime if asked?

Yes

Are you legally eligible for employment in the United States?

Yes

When will be available to begin work?

Other special training or skills (languages, machine operation, etc.)

Education

Graduate

Name and Location of School

Course of Study

No. of Years Completed

Did you Graduate?

Yes

Degree or Diploma

College

Name and Location of School

Course of Study

No. of Years Completed

Did you Graduate?

Yes

Degree or Diploma

Business/Trade/Technical

Name and Location of School

Course of Study

No. of Years Completed

Did you Graduate?

Yes

Degree or Diploma

High School

Name and Location of School

Course of Study

No. of Years Completed

Did you Graduate?

Yes

Degree or Diploma

Elementary

Name and Location of School

Course of Study

No. of Years Completed

Did you Graduate?

Yes

Degree or Diploma

Membership

Membership in Professional or Civic Organizations

(Exclude those which may disclose your race color religion or national origin)

Employment

1 - Employment Details

Company Name

Telephone

Address

Country

Employed - (State month and year)

Name of Supervisor

Weekly Pay

Job Title and Describe Your Work

Reason for leaving

2 - Employment Details

Company Name

Telephone

Address

Country

Employed - (State month and year)

Name of Supervisor

Weekly Pay

Job Title and Describe Your Work

Reason for leaving

3 - Employment Details

Company Name

Telephone

Address

Country

Employed - (State month and year)

Name of Supervisor

Weekly Pay

Job Title and Describe Your Work

Reason for leaving

4 - Employment Details

Company Name

Telephone

Address

Country

Employed - (State month and year)

Name of Supervisor

Weekly Pay

Job Title and Describe Your Work

Reason for leaving

Do Not Contact

We may contact the employers listed above unless you indicate those you do not want us to contact.

Employer Number(s)

Reason

Military

Did you serve in the U.S. Armed Forces?

Yes

If "Yes", in what Branch?

Describe any training received relevant to the position for which yur are applying.

Do Not Answer Any Question In this Section Unless the Box is checked

The information requested in needed for legally permissible, including, without limitation, national security consideration, a legimate occupational qualification or business necessity. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination based on age, citizenship and disability. The Laws of States prohibit some or all of the above types of discrimination as well as some additional types such as discrimination based upon ancestry, marital status and sexual preference.

Yes

If yes, PLease list All names (Aliases):(in the space provided below)

Are you a U.S Citizen

Yes

Are you over 18 years of age

Yes

if not, Employment is subject to verification of age

Have you been convicted of crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled expunged or sealed by a court?

Yes

If Yes Describe in full

State name of relatives and friends working for us, other than your spouse.

What is your previous Address?

How long have you been at current address?

How long were you at previous address?

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