Application for Employment at UltraCare Home Care Services

Step 1 of 5

20%

PERSONAL INFORMATION

Name*

First Last

Date of Birth:

MM slash DD slash YYYY

Address:*

City/State/Province*

Postal / Zip Code*

Home Phone Number*

Social Security Number*

Driver’s License / ID*

State*

Date of Birth*

MM slash DD slash YYYY

Email Address*

Have you ever applied for employment with this Agency?

Yes

How many days/hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

What is your expected rate of pay for this position?

How did you learn of our organization?

Newspaper Ad

Agency employee

Other

Are you willing to work:

Evenings

Weekend

Position applying for:

Educational Background

College / Graduate

School Name / Location

Major

Yrs of Study/Degree

Vo-Tech / Trade

School Name / Location

Major

Yrs of Study/Degree

High School

School Name / Location

Major

Yrs of Study/Degree

Others

School Name / Location

Major

Yrs of Study/Degree

EMPLOYMENT

List the last five years employment history, starting with the most recent employer.

1. Company Name:

Telephone:

Address:

Dates of Employment:

MM slash DD slash YYYY

Starting Pay:

Ending Pay:

Job Title and Describe Work Completed:

Reason for leaving:

2. Company Name:

Telephone:

Address:

Dates of Employment:

MM slash DD slash YYYY

Starting Pay:

Ending Pay:

Job Title and Describe Work Completed:

Reason for leaving:

3. Company Name:

Telephone:

Address:

Dates of Employment:

MM slash DD slash YYYY

Starting Pay:

Ending Pay:

Job Title and Describe Work Completed:

Reason for leaving:

Was your last name different from your present name during the above listed jobs?

Yes

If yes, what was your name?

Are you currently employed?

Yes

Do you have reliable transportation / the ability to reach multiple clients?

Yes

TWO (2) Professional / Personal Reference Check

1. Reference Full Name*

Phone*

City/State:*

Relationship to applicant*

If Professional Reference: Position Held*

2. Reference Full Name*

Phone*

City/State:*

Relationship to applicant*

If Professional Reference: Position Held*

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:

Are you capable of performing the job set forth in the job description?

Yes

If you answered No, which job requirement can you not meet?

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENTOPERATED

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I,*

authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time

Signature*

Date*

MM slash DD slash YYYY

CAPTCHA

This field is for validation purposes and should be left unchanged.

PERSONAL INFORMATION

Educational Background

College / Graduate

Vo-Tech / Trade

High School

Others

EMPLOYMENT

TWO (2) Professional / Personal Reference Check

GENERAL

Site Links

Our Services

Contact Us

Application for Employment at UltraCare Home Care Services

PERSONAL INFORMATION

Educational Background

College / Graduate

Vo-Tech / Trade

High School

Others

EMPLOYMENT

TWO (2) Professional / Personal Reference Check

GENERAL

Site Links

Our Services

Contact Us

Get In Touch With Us