General Information

    Full Name*

    Date of Application*

    Email*

    Address

    Phone Number*

    Alt Phone Number

    Can you provide verification of your legal right to work in the United States?*
    Note: If offered employment you will be required to submit documentation required by IRCA.

    Do you have relatives working for Hearts and Hands of Care or subsidiary?*

    Have you ever applied for employment at this company before?*

    Have you ever worked for Hearts and Hands of Care or subsidiary before?*


    Desired Position?*

    Desired Salary?

    Date Available*

    Have you ever used any other names?*

    (For background & criminal check)

    Do you have a Driver's License?*

    Referral Information

    How were you referred to us?*


    Work Hours, Travel and Scheduling Preferences

    Would you prefer: *
    Part-time OnlyFull-Time OnlyTemporaryNo Preference

    Hours per day, would you prefer: *
    4 or less?8Up to 12No Preference

    Hours per week, would you prefer: *
    20 or less?40Up to 60Up to 84No Preference

    What shifts would you be willing to work?*
    DayNightSwing12hr day12hr nightsNo Preference


    Education and Training Information

    Beginning with high school, list below all training and education including college, trade or vocational schools, courses such as First Aid, CPR, AED, MANDT, OSHA, apprenticeship training, and significant professional education courses or certifications.

    High School

    Location

    Years Attended

    Did you graduate?

    Degree

    Dates of Completion

     

    Trade School

    Location

    Years Attended

    Did you graduate?

    Degree

    Dates of Completion

     

    Additional Training


    Military Service

    Current Military Affiliation*
    NoneReserve (Inactive)Reserve (Active)

    Branch of Service

    From

    To

    Rank At Discharge

    Type of Discharge

    If other than honorable, explain.

    Kind of training and duty while in service


    Employment Record

    Starting with the present or most recent, list your last 10 years of employment, including self-employment, summer, and part-time jobs. If more space is needed, use the extra text block below. If you have a resume for the last 10 years of employment, you may also attach it, but complete the items below regardless. Do not put “See Resume” in this section.

    Company #1

    Name of Company

    Type of Business

    Job Title

    Supervisor's Name

    Address

    Brief Description of Job Duties

    Employment Start

    Employment End

    Wages/Salary

    May we contact your supervisor for a reference?
    YesNo

    Reason for Leaving

     

    Company #2

    Name of Company

    Type of Business

    Job Title

    Supervisor's Name

    Address

    Brief Description of Job Duties

    Employment Start

    Employment End

    Wages/Salary

    May we contact your supervisor for a reference?
    YesNo

    Reason for Leaving

     

    Company #3

    Name of Company

    Type of Business

    Job Title

    Supervisor's Name

    Address

    Brief Description of Job Duties

    Employment Start

    Employment End

    Wages/Salary

    May we contact your supervisor for a reference?
    YesNo

    Reason for Leaving

     

    Company #4

    Name of Company

    Type of Business

    Job Title

    Supervisor's Name

    Address

    Brief Description of Job Duties

    Employment Start

    Employment End

    Wages/Salary

    May we contact your supervisor for a reference?
    YesNo

    Reason for Leaving

     

    Company #5

    Name of Company

    Type of Business

    Job Title

    Supervisor's Name

    Address

    Brief Description of Job Duties

    Employment Start

    Employment End

    Wages/Salary

    May we contact your supervisor for a reference?
    YesNo

    Reason for Leaving

    Additional Space if needed...

    Resume Attachment


    Job Skills, Qualifications, and Employment Gaps

    Summarize your job skills, training and/or study that are relevant to the desired position. Also, explain any periods that you were not working.*

    Have you ever been fired, discharged or asked to resign from any position?*
    YesNo

    Have you ever been convicted of a crime? A conviction record will not necessarily bar you from employment with Hearts and Hands of Care Inc.*
    YesNo

    References (Professional - DO NOT USE FAMILY OR FRIENDS)

    List three people not related to you who have knowledge of your qualifications for the position(s) in which you may be applying:

    Reference #1

    First & Last Name*

    Phone Number*

    Years Known

    Address

     

    Reference #2

    First & Last Name*

    Phone Number*

    Years Known

    Address

     

    Reference #3

    First & Last Name*

    Phone Number*

    Years Known

    Address

     




    Part 6: Signature

    Please read carefully before signing and submitting the application!

    I hereby certify that the information contained in this application for Employment is true and complete to the best of my knowledge. I understand that any false or misleading statements or omissions regarding this application are considered sufficient grounds for disqualification from further consideration or for my dismissal if employed; and that the information in this application may be released in an authorized legal investigation. For the purpose of the certification, a photocopy of my original signature shall have the same force and effect as my original signature.

    I understand that my employment shall be contingent upon proof of identity and verification of eligibility for employment in the United States in accordance with the Immigration Reform and Control Act of 1986. I further understand that any offer of employment is contingent upon successful completion of the employment process which may include, but is not limited to, reference checks, driving record, criminal security background check, and other information bearing upon my employment fitness and qualifications.

    I consent to and authorize Hearts and Hands of Care Inc. or subsidiaries, the “Company”, to request any information concerning my previous employment, educational history, character, and background information. I hereby release all parties and persons connected with any request for information from all claims, liabilities, and damages for whatever reason arising out of furnishing such information. If employed by the Company, I further authorize the Company to provide truthful information regarding my employment to any potential or future employer and release and waive any claims against the Company for truthfully communicating any such information to a potential or future employer.

    I further understand that this Application for Employment is not a contract of employment and if I am employed I understand that my employment is for no definite period of time and may, regardless of the date of payment of wages or salary, be terminated for any reason and at any time without previous notice.

    Digital Signature

    Date Signed

    By signing above and clicking "Submit Application" you agree to the above Application Certification and Release.