Employment Application Form

* = Required Information

First Name *

Last Name *

Address 1 *

Address 2

City *

State

Zip *

Email Address *

Home Phone

Cell Phone

Are you 18 or older?

Yes

Date of Birth

Have you been convicted of a felony or been incarcerated in connection with a felony in the past seven years.

Yes

Are you a veteran?

Yes

Do you own a car?

Yes

Do you have a Driver's License?

Yes

Drivers License State

Driver's License Number

Driver's License Expiration Date

How long have you been a resident of Pennsylvania

Other Languages Spoken

Hours Available to Work

What shifts would you prefer?

Part Time or Full Time?

Yes

Previous experience

How did you hear about us?

Cover Letter

Are you legally entitled to work in the U.S.?

Yes

Level of Education

High School	College
Post College

EDUCATION	Name and Location of School	Last Year Complete	Degree	Major or Emphasis
High School
College or University
Trade School
Other

Please list any skills, training, or non-work experience that would aid you in this position as a Caregiver.

Please indicate all areas in Allegheny and Washington Counties you are willing to work.

How many years' experience do you have in the health and/or home care field?

Hourly rate desired

Date available

List the most recent employer.

Company Name / Employer

Telephone

Company Address

City, State, Zip

Dates of Employment

Pay

Position / Job Title

Supervisor

May We Contact

Yes

Reason for Leaving

Company Name / Employer

Telephone

Company Address

City, State, Zip

Dates of Employment

Pay

Position / Job Title

Supervisor

May We Contact

Yes

Reason for Leaving

Company Name / Employer

Telephone

Company Address

City, State, Zip

Dates of Employment

Pay

Position / Job Title

Supervisor

May We Contact

Yes

Reason for Leaving

Do you have a reliable car?

Yes

Are you willing to provide services to a client with a pet?

Yes

Which ones

Have you had any moving violations in the past 10 years?

Yes

Please describe

Please list your most recent employer, the phone number, the position you held, the rate of pay, duties you performed and your reason for leaving.

Please list any other relevant work or volunteer experience that we should know about.

Name

Home Phone

Cell Phone

Address

City

State

Zip

Name

Home Phone

Cell Phone

Address

City

State

Zip

Name

Home Phone

Cell Phone

Address

City

State

Zip

Comments

Attach Resume

CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete, true and accurate to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my engagement with Happy at Home - In Home Care Inc. I authorize Happy at Home - In Home Care Inc. and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release Happy at Home - In Home Care Inc. from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during engagement with Happy at Home - In Home Care Inc. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during my engagement with Happy at Home - In Home Care Inc. I understand that this application is not a contract of employment. My engagement with Happy at Home - In Home Care Inc. is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if retained by Happy at Home - In Home Care Inc., the work relationship between Happy at Home - In Home Care Inc., and myself is at-will, so that both Happy at Home - In Home Care Inc. and I remain free to choose to end our work relationship with proper notice per the Caregiver/Independent Contractor Agreement. In order for you to receive client referrals about your work proper notice to leave Happy at Home - In Home Care Inc. must be given. Any changes in this work engagement must be in writing. I understand due to the nature of this business/industry, no guarantee can ever be made as to the schedule hours or the amount of hours assigned to work. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I furthermore understand that due to the nature of the business, no amount of work can be guaranteed. I understand that this application is not a contract for employment.

By typing your full name and providing the date below you are electronically signing this document. The name listed here will be considered the legal and binding mark of the applicant completing this application.

Check this box and type in your Full Name (First and Last) and fill in the date if you fully understand and agree to the terms above.

Full Name *

Date *

CNA	HHA	NA	RN
LPN	None	Other