EMPLOYMENT APPLICATION

This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated agency Sara’s helping Hands. 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.

Fields marked with an * are required

Header

APPLICATION

Today's Date

Positions(s) Applied For

First Name *

Middle Name

Last Name *

Current Address

Address

Apt #

City

US State

Zip

Previous Address

Address

Apt #

City

US States

Zip

Phone Number

PHONE

Home Phone

Cell Phone *

Work Phone

Alternate Phone

Emergency Contact 1

Name *

Phone *

Emergency Contact 2

Name *

Phone *

Vehicle

VEHICLE

Do you have a vehicle? *

Do you have a valid drivers license? *

Do you have vehicle insurance? *

Are you a US Citizen?

Can you legally work in the United States?

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Have you ever submitted an application here before? *

If yes, when?

Have you ever been employed here before? *

If yes, when?

How did you hear about us? *

Have you been given a copy of the job description for the position for which you have applied to review? *

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? *

Why are you interested in employment with us? *

Availability

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule of the amount of hours worked.

What date are you available to begin work? *

Please complete all areas of availability

Mornings
Afternoon
Evenings
Overnights
Weekdays
Weekends

Please indicate the days of the week as well as the earliest and latest times that you are available for work. *

Please indicate the types of services which you are willing to provide

Companionship
Meal Preparation
Activities (games/crafts)
Housekeeping (dust/vacuum)
Laundry/Ironing
Medication Reminders
Errands/Shopping/Transportation*
Personal Care
Dementia/Alzheimer's Care

*In order to be able to provide transportation or run errands, you will be required to have a valid driver's license and current auto insurance. A motor vehicle record check will be conducted, and proof of insurance will be required.

Are you willing to provide service to a client with a pet? *

If yes, which ones:

Cats
Dogs

Are you willing to provide service to a client that smokes? *

Job Related Skills

JOB RELATED SKILLS

Describe any training or life skills you have that apply to caring for individuals with disabilities *

Describe any work history you have that would apply to caring for individuals with disabilities *

What do you like (or think you would like) most about working with individuals with disabilities? *

What do you like (or think you would like) least about working with individuals with disabilities? *

What personal rewards do you get from working with individuals with disabilities? *

Education

EDUCATION

Please select the highest grade completed *

Grade School 6th
Grade School 7th
Grade School 8th
High School 9th
High School 10th
High School 11th
High School 12th
College 13th
College 14th
College 15th
College 16th
College 16th+

High School

School Name

City

US States

# of Years Attended

Graduated

Vocational/Technical

School Name

City

US States

# of Years Attended

Graduated

College/University

School Name

City

US States

# of Years Attended

Graduated

Work History

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Most Recent Employer

Are you currently working for this employer? *

If yes, may we contact?

Company Name

City

US States

Phone Number

Dates of Employment

Job Title

Supervisor's Name

Duties

Salary

Reason for Leaving

Second Most Recent Employer

Company Name Copy

City

US States

Phone Number

Dates of Employment

Job Title

Supervisor's Name

Duties

Salary

Reason For Leaving

Third Recent Employer

Third Most Recent Employer

Company Name

City

US States

Phone Number

Dates of Employment

Job Title

Supervisor's Name

Duties

Salary

Reason For Leaving

Security

SECURITY

*Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check. As a condition of employment all employees must be “Bondable” & “Insurable”.

Are you at least 19 years of age? *

List states and counties of residence for the past seven years.

Have you been charged/convicted of a felony and/or misdemeanor/or served time?

If yes, please describe

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

References

References (Do Not Include Relatives)

Please complete at least three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 6 references, you will be asked to provide additional references.

Reference 1

Full Name *

Phone Number *

Best Time of Day to Call *

Relationship *

Number of Years Known *

Reference 2

Full Name *

Phone Number *

Best Time of Day to Call *

Relationship *

Number of Years Known *

Reference 3

Full Name

Phone Number

Best Time of Day to Call *

Relationship *

Number of Years Known *

Reference 4

Full Name

Phone Number

Best Time of Day to Call

Relationship

Number of Years Known

Reference 5

Full Name

Phone Number

Best Time of Day to Call

Relationship

Number of Years Known

Reference 6

Full Name

Phone Number

Best Time of Day to Call

Relationship

Number of Years Known

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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 and true 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 employment. I authorize the company 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 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 SARAS HELPING HANDS, 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.

Electronic Signature *

Typing my name below serves as my electronic signature. By my signature, I certify the information provided on and in connection with this application is true, accurate, and complete.

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