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Employment Application
Employment Application
allinallhome
2023-08-31T19:19:42+00:00
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Name
First
Middle
Last
Date
MM slash DD slash YYYY
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Email
Referred to us by:
Position(s) applied for:
HHA
PCA
CNA
LPN
RN
Other
Type of employment desired
Full-Time
Part-Time
Casual
Please Specify Days and Hours
If currently employed, may we contact your employer?
Yes
No
Rate of Pay Expected (per hour)
Is there a specific reason you are applying for employment at this company?
Yes
No
If answered Yes above, please briefly outline the reason:
Are you legally eligible for employment in this country?
Yes
No
Are you available to work overtime if required?
Yes
No
Have you applied with this company before?
Yes
No
Have you been employed at this company before?
Yes
No
If answered yes above, when? and at what location?
Do you have any friends or family employed at this location?
Yes
No
Have you been convicted of a crime in the last seven (7) years?
Yes
No
If answered yes above, please explain
Depending on the offense, conviction may NOT necessarily be a disqualification for employment.
If considered for hiring, will you agree to provide a criminal background check?
Yes
No
Educational Background
School
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Degree(s) Diploma(s) Earned
Graduated?
Yes
No
School
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Degree(s) Diploma(s) Earned
Graduated?
Yes
No
School
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Degree(s) Diploma(s) Earned
Graduated?
Yes
No
What Nursing or relevant designations, licenses or registrations if any, do you possess?
Type
Date of Most Recent Registration
Valid in State/Province?
Yes
No
Type
Date of Most Recent Registration
Valid in State/Province?
Yes
No
Do you have the following?:
CPR
No
Yes
Last Certified
First Aid
No
Yes
Last Certified
Are you a...? (Click all that apply)
CNA
Home Health Aide?
LPN
RN
If yes, answer the following three questions.
1. Licensed / Certification #
Date Issued
2. License-issuing authority or board:
3. Expiration Date:
PLEASE ANSWER THE FOLLOWING QUESTIONS
Have you ever filed for workers compensation?
Yes
No
Have you ever collected unemployment?
Yes
No
If Yes, Explain:
When can you work?
1. Date available to start:
Month
Day
Year
2. Do you prefer to start work in the:
Morning
Afternoon
Evening
Night
3. How many hours per week are you willing to work?
4. Are you willing to work some weekends?
Yes
No
5. Are you willing to work some work holidays?
Yes
No
Do you have any experience working with the elderly, children, and/or disabled individuals?
Yes
No
If yes, Please briefly state your experience:
EMPLOYMENT BACKGROUND
Provide the following information beginning with the most recent employer.
Employer
Phone
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Job Title
Immediate supervisor and title and phone number
Reason for leaving:
May we contact for reference?
Yes
No
Later
Dates Employed
From
To
Starting hourly rate/salary
Final hourly rate/salary
Summarize the type of work performed and job responsibilities
Employer
Phone
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Job Title
Immediate supervisor and title and phone number
Reason for leaving:
May we contact for reference?
Yes
No
Later
Dates Employed
From
To
Starting hourly rate/salary
Final hourly rate/salary
Summarize the type of work performed and job responsibilities
Employer
Phone
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Job Title
Immediate supervisor and title and phone number
Reason for leaving:
May we contact for reference?
Yes
No
Later
Dates Employed
From
To
Starting hourly rate/salary
Final hourly rate/salary
Summarize the type of work performed and job responsibilities
Employer
Phone
Address
City
State / Province / Region
ZIP / Postal Code
Job Title
Immediate supervisor and title and phone number
Reason for leaving:
May we contact for reference?
Yes
No
Later
Dates Employed
From
To
Starting hourly rate/salary
Final hourly rate/salary
Summarize the type of work performed and job responsibilities
References
List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).
Name
First
Last
Relationship
Years Acquainted
Phone
Name
First
Last
Relationship
Years Acquainted
Phone
Name
First
Last
Relationship
Years Acquainted
Phone
Applicant Note:
This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead Senior Care franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.
Employment Acknowledgment
I certify that all the information I have provided is true, complete and correct. I understand that if I am hired, I will be required to provide criminal background check, proof of identity and legal authority to work in the USA, proof of certifications or educational qualifications, drug test, and a drivers abstract (if applicable). I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal/termination. I release this company from any liability, which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between All in All Home Care, LLC and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. Furthermore, this application does not in any way constitute an agreement or contract for employment. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
Applicant Signature
Check here to acknowledge that you agree to the terms of agreement.
Employee Consent for Reference Check
To Whom It May Concern, I (name here) hereby, give my former employer (s), authorization to provide a reference check to my potential employer.
Applicant Signature
I am aware and acknowledge the information referred to above is not shared with any third parties. By signing below I give the employer consent to collect the information contained herein and use for the purpose specified.
Date
MM slash DD slash YYYY
Sworn Statement Or Affirmation
Section 32.1-162.9 of the Code of Virginia requires that any person desiring to work at a licensed home care organization shall provide the hiring facility with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside the Commonwealth of Virginia. The law prohibits licensed home care organizations from hiring any individuals convicted of a barrier crime (specified at the back page). However, applicants convicted of one misdemeanor barrier crime not involving abuse or neglect may be hired if five years has elapsed since the conviction. Any person making a false statement on this form regarding any criminal offense shall be guilty of a Class 1 misdemeanor. Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.
Name
First
Middle
Last
Social Security Number
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law?
Yes
No
If yes, List all and explain:
Are you the subject of any pending criminal charges?
Yes
No
If yes, please explain:
Applicant Signature
I hereby affirm that the information provided on this form is true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment offered by this facility. I understand that all information on this form is subject to verification.
Date
MM slash DD slash YYYY
Note to Licensee: This form must me retained for all compensated employee
Authorization For Background Check
I authorize the All in All Home Care, LLC to order my background report, including investigative consumer reports. I understand that the Company may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law. The information requested below is collected solely for the purpose of aiding the Company in running a background check in connection with your application for employment. The employer is requesting that you provide this information to assist in conducting a thorough background check. I agree All in All Home Care, LLC may rely on this authorization to order background reports, including investigative consumer reports, from companies without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal information I provided is true and correct.
Name
First
Middle
Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Driver's License Number
State Issuing License
Enter Any Other Names Used (including maiden names):
First
Last
First
Last
Addresses Within The Past Seven Years
Present Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Prior Street Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Prior Street Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Prior Street Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Please upload any available documents below:
CPR/FIRST AID
LICENSE (TYPE: CNA, HHA, LPN, RN)
ID/DL
OTHER CERTIFICATES
GREEN CARD/NATURALIZATION CERTIFICATE/BIRTH CERTIFICATE
HEALTH RECORDS (PPD/CXR/COVID/FLU)
File Upload(s)
Drop files here or
Select files
Max. file size: 50 MB.
ALL IN ALL HOME CARE
Consent for drug/alcohol screening test
All in All Home care has a drug/alcohol free work place policy. If you are offered and accept employment with All in All Home Care, and during your tenure of employment, in the interest of safety for all concerned, you might be required to take a urine test for drug and/or alcohol use. I, ______________________________, have been fully informed of the reason for this urine test for drug and/or alcohol (I understand what I am being tested for), the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will become part of my record. If this test is positive, I might not be hired or my employment with All in All Home Care will be terminated if I am already an employee with the agency. I understand that I will be given the opportunity to explain the results of this test.
Applicant Signature
I Acknowledge the terms of agreement described above.
Date
Month
Day
Year
Comments
This field is for validation purposes and should be left unchanged.
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