Employment Application | All in All Home Care

Name

First Middle Last

Date

Address

Street Address City State ZIP Code

Phone

Email

Referred to us by:

Position(s) applied for:

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

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

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 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

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

Social Security Number

Driver's License Number

State Issuing License

Enter Any Other Names Used (including maiden names):

First Last

Addresses Within The Past Seven Years

Present Address

Street Address City State ZIP Code

Prior Street Address

Street Address City State ZIP Code

From Date

To Date

Prior Street Address

Street Address City State ZIP Code

From Date

To Date

Prior Street Address

Street Address City State ZIP Code

From Date

To Date

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

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

Email

This field is for validation purposes and should be left unchanged.

Educational Background

What Nursing or relevant designations, licenses or registrations if any, do you possess?

Do you have the following?:

If yes, answer the following three questions.

PLEASE ANSWER THE FOLLOWING QUESTIONS

When can you work?

EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.

References

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

Applicant Note:

Employment Acknowledgment

Employee Consent for Reference Check

Sworn Statement Or Affirmation

Note to Licensee: This form must me retained for all compensated employee

Authorization For Background Check

Addresses Within The Past Seven Years

ALL IN ALL HOME CARE

Consent for drug/alcohol screening test

Better Care Starts With You