Employment Application

Full Legal Name

First name	Middle name	Last name

Contact Info

Email address	Home phone	Work phone

Address

Street and P.O. Box	City	State	Zipcode

Employment Details

Title of Desired Position:

Choose Appropriate Schedule:

Full Time
Part Time

*Have you ever been convicted of a crime other than minor traffic offenses?

Are you able to perform all the functions of the job you are applying for?

(Click here to review job descriptions)

* If you check "Yes" to this question you will be asked for further information if you are under consideration to become a finalist for this position

Education Summary

High School:	0 1 2 3 4
College or University:	0 1 2 3 4
Graduate:	0 1 2 3 4

Select highest grade completed:
Complete the following information:

School/Institution	Name and Location	No. Years Completed	Did you graduate?	Course of Study	Degree Certificate
High School
Junior College
Other College or Universitiy
Graduate School
Business, Trade, or Service Schools

Other Training

Have you had any specialized training, special skills or hold any cerificates or licenses that would be relevant to the job for which you are applying?

If yes, please estimate number of hours:

and describe training:

Previous Employment List

Most recent job first

Employer:
Department:
Street:
City:
Telephone:
Supervisor:
Job title:
Job duties:
FROM (M/D/Y):
TO (M/D/Y):
Hours:	Full Time Part Time
Reason for Leaving:

Employer:
Department:
Street:
City:
Telephone:
Supervisor:
Job title:
Job duties:
FROM (M/D/Y):
TO (M/D/Y):
Hours:	Full Time Part Time
Reason for Leaving:

Employer:
Department:
Street:
City:
Telephone:
Supervisor:
Job title:
Job duties:
FROM (M/D/Y):
TO (M/D/Y):
Hours:	Full Time Part Time
Reason for Leaving:

If currently employed, may we contact your present employer?

NOTE: The Immigration Reform Act of 1986 requires verification
of the right to work in the United States as a condition of hire.

I declare that the information in this application is true and complete to the best of my knowledge and I authorize investiation of all statments herein recorded. I authorize Home Health Services, Inc or any of its components to make reference checks relating to my employment and I also authorize all prior employers to provide full details concerning my past employment. I release from all liability persons and organizations reporting information required by this application. I understand that I will be subject to dismissal if any statement in this application is found to be untrue.

I ACCEPT THE ABOVE STATEMENT(S):

References

Give name, address, and telephone number of three business references who are not related to you. Include how long and how you know these references.

Name:
Address:
Telephone Number:
How long have you known this reference?
How do you know this reference?

Name:
Address:
Telephone Number:
How long have you known this reference?
How do you know this reference?

Name:
Address:
Telephone Number:
How long have you known this reference?
How do you know this reference?

Please read carefully before submitting this application The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification of refusal of employment, or if employed termination from the Company.

Any offer of employement I may receive from the Company is contingent upon my successful completion of the Company's total pre-employment drug screen and criminal background check and my satisfactory completion of any post offer pre-employment medical examination that the company may require. I also agree, if employed, to submit to a medical examination at any time at the Company's request. I hereby consent to having the results of any post offer pre-employment and post-employment medical exams that I may be required to take disclosed to the Company

I understand that as a condition of employment, I will be required to undergo and successfully pass a screening for drugs and/or alcohol. I also understand and agreee that, if employed, I may be required to submit to a drug and/or alcohol screening at any time at the discretion of the Company.

In processing my application for employment, the Company may verify all the information provided by me concerning my prior employemtn, education, character, general reputation, personal characteristics and criminal record. 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 understand that employment at this Company is "at will", which means that either I or the Company can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment is continued on that basis. I understand that no supervisor, manager, or representative of the company, other than the Chief Executive Officer has any authority to alter the foregoing.

I certify that the information provided above is true and complete, and I hereby acknowledge that I have read, understand and agree to the preceding statements.