Application Test | Partners in Home Care Toledo

Personal Information

Position Applying For*

Date of Birth*

MM/DD/YYYY

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Have you ever pled guilty or “no contest” to, or been convicted of, a misdemeanor or felony?*

Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial? If no, write 'no'. If yes, give the date(s) and details:*

Answering “Yes” to these questions does not constitute an automatic bar to employment. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account. (Do not include minor traffic infractions and convictions for which the record has been sealed or expunged).

Are you able to satisfactorily perform the essential job duties required of the position for which you are applying, either with or without accommodations?*

Availability

Please indicate Days and hours of availability below:

Sunday

Days

Afternoons

Midnights

Monday

Days

Afternoons

Midnights

Tuesday

Days

Afternoons

Midnights

Wednesday

Days

Afternoons

Midnights

Thursday

Days

Afternoons

Midnights

Friday

Days

Afternoons

Midnights

Saturday

Days

Afternoons

Midnights

Available to work holidays?*

Date available to start*

Do you have current CPR Certification?*

Certification Expiration Date*

Do you have a current Driver’s license?*

Do you have adequate transportation to and from work?*

Do you have current automobile insurance?*

Have you served in the United States Armed Forces?*

Additional training skill, experience, and special achievements relevant to position:*

Education

High School

Name of High School*

Years Completed*

Please enter a number from 0 to 4.

Graduation Date

MM/YYYY

College

Name of College

Years Completed

Please enter a number from 0 to 10.

Graduation Date

MM/YYYY

Degree Earned

Graduate School

Name of Graduate School

Years Completed

Please enter a number from 0 to 10.

Graduation Date

MM/YYYY

Degree Earned

Employment History

Are you currently employed?*

May we contact your present employer?*

Have you ever applied or worked for this company before?*

If no, write 'no'. If yes, specify dates

Previous Employer 1

Name and Address of Employer

From

MM/YYYY

To

MM/YYYY

Initial Position and Final Position

Starting and Ending Pay

Supervisor Phone

Reason for Leaving

Previous Employer 2

Name and Address of Employer

From

MM/YYYY

To

MM/YYYY

Initial Position and Final Position

Starting and Ending Pay

Supervisor Phone

Reason for Leaving

Previous Employer 3

Name and Address of Employer

From

MM/YYYY

To

MM/YYYY

Initial Position and Final Position

Starting and Ending Pay

Supervisor Phone

Reason for Leaving

Additional Information

Have you been terminated or asked to resign from any job?*

If yes, explain the circumstances. If no, write 'no'.

Please explain fully any gaps in your employment history

Do you have any friends or relatives who work for the company?*

If yes, who? If no, write 'no'.

Personal References

List three personal references that are not previous employers or relatives.

Reference 1 Name*

Address

Phone

Reference 2 Name*

Address

Phone

Reference 3 Name*

Address

Phone

Signature

This company is an equal opportunity employer dedicated to nondiscrimination in employment. The company selects the best- qualified individual for the job based on job-related qualifications regardless of race, age, color, religion, sex, national origin, ancestry, marital status, disability, or any basis protected by applicable law.

This application will be considered active for a maximum of thirty (30) days. If you wish to be considered for employment after that time, you must reapply.

I Certify that all information that I have provided on this application is true and accurate:

Full Name*

By entering your name in this field, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement.

Background Check Authorization

Complete all items on this page unless otherwise directed.

The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and shall not be used for any other purpose.

Full Legal Name*

Gender

Other names you have used

Driver's License #

Issuing State

Birth Date*

MM/DD/YYYY

Place of Birth*

Include both city and state.

Current Address*

Street Address City State ZIP Code

County*

How long at this address?*

Previous Address 1

Address

Street Address City State ZIP Code

County

How Long at this Address?

Previous Address 2

Address

Street Address City State ZIP Code

County

How Long at this Address?

Previous Address 3

Address

Street Address City State ZIP Code

County

How Long at this Address?

Authorization

I authorize Partners In Home Care, LLC (PHC) and/or its agents to request a consumer report, or investigative consumer report about me for the purpose of evaluating me for employment, promotion, reassignment, or retention as an employee. I understand that background reports will be requested on me, including credit reports, criminal convictions, employment history, education, professional references, personal references, civil court filings, driving records and insurance records. These reports may include information as to my character, general reputation, personal characteristics, mode of living, work habits, salary history, performance, education, experience, reasons for termination of employment, and any history of criminal, dishonest, or violent behavior. Further, I understand that requests for information will be made of various private and government agencies, which maintain records concerning my past activities.

I release Partners In Home Care, LLC and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liability claims or damages that may occur directly or indirectly result from the use of, disclosure, or release of any such information by any person or party, whether such information is favorable or unfavorable to me.

I understand that I have the right to make a written inquiry within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.

Your Full Name*

By entering your name in this field, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement.

Applicant’s Statement & Agreement

In the event of my employment to a position in this Company, I will comply with all rules and regulations of this Company. I understand that the Company reserves the right to require me to submit to a test for the presence of drugs in my system prior to employment and at any time during my employment, to the extent permitted by law. I also understand that any offer of employment may be contingent upon the passing of a physical examination and a test for the presence of alcohol in my system, performed by a doctor selected by the Company. Further, I understand that any time after I am hired, the Company may require me to submit to physical examination and an alcohol test, to the extent permitted by law. I consent to the disclosure of the results of any physical examination and related tests to the Company. I also understand that I may be required to take other tests such as personality tests or honesty tests, prior to employment and during my employment. I understand that should I decline to sign this consent or decline to take any of the above tests, my application for employment may be rejected or my employment may be terminated.

Drug screening may be done initially and retested or initiated at supervisor’s discretion if drug use/abuse is suspected.

I understand that the company may investigate my driving record and my criminal record and that an investigation consumer may be prepared whereby information is obtained through personal interviews with personal references, and others whom I am acquainted. This inquiry includes information as to my character, general reputation, and personal characteristics. I understand that I have the right to make a written inquiry, within a reasonable period of time, to receive additional detailed information about the nature and scope of this investigation. I further understand that the Company may contact my previous employers and I authorize those employers to disclose to the Company all records and information pertinent to my employment with them. In addition to authorizing the release of any information regarding my employment, I hereby fully waive any rights or claims I have or may have against my former employers, their agents, employees and representatives, as well as other individuals who release information to the Company, and release them from any and all liability, claims, or damages that may directly or indirectly result from the use, disclosure, or release of any such information by any person or party, whether such information I favorable or unfavorable to me. I authorize the persons named herein as personal references to provide the Company with any pertinent information they may have regarding myself.

I hereby state that all the information that I provided on this application or any other documents filled out in connection with my employment, and in any interview is true and correct. I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that if I am employed and any such information is later found to be false or incomplete in any respect, I may be dismissed. I understand if selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigrations laws require me to complete an I-9 Form in this regard.

If hired, I agree as follows: My employment and compensation is terminable at-will, is for no definite period, and my employment and compensation may be terminated by the Company at any time and for any reason whatsoever, with or without good cause at the option of either the Company or myself. No implied, oral, or written agreement contrary to the expressed language of this agreement is valid unless they are in writing and signed by the Administrator. No supervisor or representative of the Company other that the Administrator has the authority to make any agreements contrary to forgoing. This agreement is the entire agreement between the Company and the employee regarding the rights of the Company or employee to terminate employment with or without good cause, and this agreement takes the place on all prior agreements, representations, and understandings of the employee and the Company.

If you have questions regarding this statement, please ask a Partners in Home Care, LLC representative before signing. I hereby acknowledge that I have read the above statements and understand the same.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT & AGREEMENT

Your Full Name*

By entering your name in this field, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement.

Application

Personal Information

Availability

Education

High School

College

Graduate School

Employment History

Previous Employer 1

Previous Employer 2

Previous Employer 3

Additional Information

Personal References

Signature

Background Check Authorization

Previous Address 1

Previous Address 2

Previous Address 3

Authorization

Applicant’s Statement & Agreement

Company

Employee Links

Contact

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