Employment Application Form

* = Required Information

Angel Heart Home Care is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Applicant Information

Applicant Name *

Address *

City *

State *

Zip Code *

Telephone Number *

Email Address *

Date of Application *

Employment Position

Position(s) applying for: Caregiver

How did you hear about this position? *

What days are you available for work? *

What hours or shift are you available for work? *

If needed, are you available to work overtime? *

Yes

On what date can you start working if you are hired? *

Do you have reliable transportation to and from work? *

Yes

Personal Information

Have you ever applied to or worked for Angel Heart Home Care before?

Yes

When?

Do you have any friends, relatives, or acquaintances working for Angel Heart Home Care?

Yes

State name and Relationship

Are you 18 years of age or older?

Yes

Are you a United States citizen or approved to work in the United States?

Yes

What document can you provide as proof of citizenship or legal status?

Do you have any condition which would require job accommodations?

Yes

Please describe accommodations required below.

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes

Please state the nature of the crime(s), when and where convicted and disposition of the case:

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)s

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Angel Heart Home Care complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)

Education and Training

High School

Location (City, State)

Year Graduated

Degree Earned

College/University

Location (City, State)

Year Graduated

Degree Earned

Vocational School/Specialized Training

Location (City, State)

Year Graduated

Degree Earned

Military

Are you a member of the Armed Forces?

Yes

What branch of the military did you enlist?

What was your military rank when discharged?

How many years did you serve in the military?

What military skills do you possess that would be an asset for this position?

Previous Employment

Employer Name

Job Title

Supervisor Name

Employer Address

City

State

Zip Code

Employer Telephone

Dates Employed

Reason for Leaving

Employer Name

Job Title

Supervisor Name

Employer Address

City

State

Zip Code

Employer Telephone

Dates Employed

Reason for Leaving

Employer Name

Job Title

Supervisor Name

Employer Address

City

State

Zip Code

Employer Telephone

Dates Employed

Reason for Leaving

References

Please provide 2 personal and professional reference(s) below:

Reference

Contact Information

Reference

Contact Information

At-Will Employment

The relationship between you and the Angel Heart Home Care is referred to as "employment at will". This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Angel Heart Home Care. No representative of Angel Heart Home Care has the authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will", and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature *

Clear

Dated