Career Home Career Apply Now Step 1 of 5 20% Name First Middle Last Date MM slash DD slash YYYY Social Security Number Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TelephoneCell PhoneEmail Referred to us by Position(s) applied for Caregiver Nursing Other Date available Type of employment desired Full-Time Part-Time Casual Please Specify Days and Hours If currently employed, may we contact your employer? Yes No If yes, then when and where? Rate of Pay Expected $_ per hour Is there a specific reason you are applying for employment at this company? Yes No If Yes, 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 Have you been convicted of a crime in the last seven (7) years? Yes No Do you have any friends or family employed at this location? Yes No If yes, then when and where? If yes, please explain CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT.If considered for hiring, will you agree to provide a criminal background check? Yes No If considered for hiring, will you agree to provide a drivers record? Yes No N.A EMPLOYMENT BACKGROUNDProvide The Following Information Beginning With The Most Recent Employer.Employment Background <div class="repeater-field-header"> <div class="repeater-field-header-title"> <span class="repeater-field-header-count">1</span></div> <div class="repeater-field-header-acctions"> <ul> <li><i class="repeater-icon icon-down-open repeater-field-header-acctions-toogle" aria-hidden="true"></i></li> <li><i class="repeater-icon icon-cancel-1 repeater-field-header-acctions-remove" aria-hidden="true"></i></li> </ul> </div> </div> Employer TelephoneAddress Street Address From MM slash DD slash YYYY To MM slash DD slash YYYY Hourly Rate/salary Starting $ Per Hourly Rate/salary Final $ Per Summarize The Type Of Work Performed And Job Responsibilities Reason For Leaving May We Contact For Reference? Yes No Later EDUCATIONAL BACKGROUNDList Previous Three (3) Educational Institutions Attended, Beginning With The Most Recent.School City, State/province Graduated? Yes No Degree(S)/diploma(S) Earned What, Licenses Do You Possess? Type Valid In State/province ? Yes No Do you have the following:CPR No Yes First Aid No Yes Last Certified Last Certified List The Name, Relationship, Number Of Years Acquainted, And Phone Number Of Three References. (No Relatives Please).Name First Relationship Years Acquainted Phone Number I Certify That All The Information I Have Provided Is True, Complete And Correct. The Information Contained Within This Application, Or Any Cover Letter Or Resume Attached Is Not Shared With Any Third Parties. The Information Is Used By The Employer Only As An Aid In The Hiring Decision Making Process. The Applicant, By Signing The Application Gives The Employer Consent To Collect The Information Contained Herein And Use For The Purpose Specified. 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. I Understand That If I Am Hired, I Will Be Required To Provide Criminal Background Check At My Cost, Proof Of Identity And Legal Authority To Work In The United States Furthermore, I Understand And Agree That If Employed, I Am Free To Resign At Any Time, With A 2-week Notice. The Employer Reserves The Same Rights To Terminate My Employment At Any Time, With Or Without Prior Notice, Except As May Be Required By Law. This Application Does Not In Any Way Constitute An Agreement Or Contract For Employment. SignatureDate MM slash DD slash YYYY For office use only:Date application received: Date applicant contacted: I & J's Home CareEmployee Consent For Background CheckI 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.I Give, I & J’s Home Care My Potential Employer, Authorization To Obtain A Background Check For Employment.Print Name Sign Name Address Street Address Notes: Do you have question?Feel free to contact us anytime Contact us
