Application for Employment

Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on back of application. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Job Applied For (PCP, RN, Secretary, CNA, etc.)

Today’s Date

Are you seeking:

Full-time

Part-time

Temporary

When could you start work?

Name

First Middle Last

Telephone Number

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Are you 18 year of age or older?

Yes

(If you are hired you may be required to submit proof of age.)

Social Security #

If hired, can you furnish proof you are eligible to work in the U.S.?

Yes

Have you ever applied here before?

Yes

If yes, when?

Were you ever employed here?

Yes

If yes, when?

Have you ever been convicted of any law violation (except a minor traffic violation)?

Yes

If yes, give details:

(A “Yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered.

Are you now or do you expect to be engaged in any other business or employment?

Yes

If yes, please explain:

For Driving Jobs Only: Do you have a valid driver’s license?

Yes

Driver’s License Number

State of License

Class of License

Have you had your driver’s license suspended or revoked in the last 3 years?

Yes

If yes, give details:

List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal age over 40, race, sex, color, religion, national origin, disability or other protected status.)

LIST NAME AND ADDRESS OF SCHOOLS

High School or GED

# of Years Completed

Diploma/ Completed Degree/ Certificate

Subjects Studied

College or University

# of Years Completed

Diploma/ Completed Degree/ Certificate

Subjects Studied

Vocational or Technical

# of Years Completed

Diploma/ Completed Degree/ Certificate

Subjects Studied

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. PLEASE GIVE MONTH AND YEAR.

NAME OF EMPLOYER

JOB TITLE AND DUTIES

ADDRESS

DATES OF EMPLOYMENT: FROM - TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR

TELEPHONE

REASON FOR LEAVING

NAME OF EMPLOYER

JOB TITLE AND DUTIES

ADDRESS

DATES OF EMPLOYMENT: FROM - TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR

TELEPHONE

REASON FOR LEAVING

NAME OF EMPLOYER

JOB TITLE AND DUTIES

ADDRESS

DATES OF EMPLOYMENT: FROM - TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR

TELEPHONE

REASON FOR LEAVING

NAME OF EMPLOYER

JOB TITLE AND DUTIES

ADDRESS

DATES OF EMPLOYMENT: FROM - TO

CITY, STATE, ZIP CODE

PAY: START $ FINAL $

SUPERVISOR

TELEPHONE

REASON FOR LEAVING

Have you worked or attended school under any other name?

Yes

If yes, give names

Are you presently employed?

Yes

If yes, may we contact your present employer?

Yes

Have you ever been fired from a job or asked to resign?

Yes

If yes, please explain

Give three references, not relatives or former employers.

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.
I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.
I authorize the investigation of any of all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organization from any legal liability in making such statements.
I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.
I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE. I have read, understand, and by my signature consent to these statements.

Signature

Date

This application for employment will remain active for a limited time. Ask the organization representative for details.

EMPLOYEE AVAILABILITY

Please provide the following information on your availability to work for Professional Home Health Care.

Type of Transportation you have / will use for home visits:

Do you have any allergies that would affect your work at PHHC?

Yes

If yes, please list here:

Do you have a problem working with a client who smokes?

Yes

How many hours are you willing to work per week?

Locations willing to work (circle those that apply, and/or write in additional locations):

Boulder/ Longmont

Denver

Colorado Springs

Fountain

Woodland Park

Other

Pueblo

Pueblo West

Other

Please Check (X) the Day and Time of Week You Are Available

SUN

MON

TUE

WED

THUR

FRI

SAT

PHHC TELEPHONE REFERENCE CHECK FORM - # 1

EMPLOYMENT INFORMATION

To be completed by Applicant

Name of first Professional Reference To Be Contacted_

Title

Company Name

Phone

Reason for leaving this company:

I authorize the company I worked for and/or the individual listed above to release information about me to Professional Home Health Care, Inc.

Applicant Signature

Date

*FOR OFFICE USE ONLY

EMPLOYMENT VERIFICATION: To be completed by employer

`interviewer_form.html` ```html Interviewer Introduction Form

[INTERVIEWER: Introduce yourself, identify our company] “One of your former employees, , has applied for employment at our company as a . Hopefully, you will give me some insight on and whether this is a suitable position for . May I ask you a few questions?”

```

What was his/her position?

What were the dates of his/her employment?

What was your relationship to him/her? (e.g., supervisor, co-worker, etc)

What were his/her strengths as an employee?

How would you rate his/her overall performance?

If you had an opening today for the same job, would you hire him/her? Why/why not?

`interviewer_followup_form.html` ```html Interviewer Follow-up Questions Form ```

If we were to extend an employment offer, what suggestions would you give us to help contribute toward ______’s success on the job?

Is there anything else you think would be helpful for us to know about in making our hiring decision?

Name of Interviewer:

Date

PHHC TELEPHONE REFERENCE CHECK FORM - # 2

EMPLOYMENT INFORMATION: To be completed by Applicant

Name of second Professional Reference To Be Contacted

Title

Company Name

Phone

Reason for leaving this company:

I authorize the company I worked for and/or the individual listed above to release information about me to Professional Home Health Care, Inc.

Applicant Signature

Date

*FOR OFFICE USE ONLY

EMPLOYMENT VERIFICATION: To be completed by employer

`interviewer_form.html` ```html Interviewer Introduction Form ```

What was his/her position?

What were the dates of his/her employment?

What was your relationship to him/her? (e.g., supervisor, co-worker, etc)

What were his/her strengths as an employee?

How would you rate his/her overall performance?

If you had an opening today for the same job, would you hire him/her? Why/why not?

`interviewer_followup_form.html` ```html Interviewer Follow-up Questions Form ```

If we were to extend an employment offer, what suggestions would you give us to help contribute toward ______’s success on the job?

Is there anything else you think would be helpful for us to know about in making our hiring decision?

Name of Interviewer:

Date

BACKGROUND CHECK AUTHORIZATION

APPLICANT Complete the following information as accurately as possible. (Please Print Clearly.)

Last:

First:

MI:

SSN*:

D.L. #:

State:

Birth date*:

Phone

Professional License Type:

State:

Expiration Date:

Other/Previous names:

Date Changed:

(Attach additional sheet, if necessary.)

Date Changed:

Addresses: (List past seven years beginning with your current address. Include street, city, state, zip code, county and dates of residence. Attach additional sheet, if necessary.)

City

State

Zip

County

Dates

City

State

Zip

County

Dates

City

State

Zip

County

Dates

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the FCRA required documents DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT which are both available at https://www.trudiligence.com/downloadforms.php and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, workers compensation bureau, testing laboratory or insurance company to furnish any and all background information requested by TruDiligence, LLC, 3190 S Wadsworth Blvd, Suite 260, Lakewood, CO 80227, 800-580-0474, or another outside organization acting on behalf of Employer, and/or Employer itself. I understand that these files may contain negative information about my background, mode of living, character and personal reputation; therefore I agree to defend and hold harmless TruDiligence and any agent acting on its behalf, from any and all liability arising through the investigation of my background. If applicable, I hereby authorize the release of my confidential report to any Third Party directly involved in the hiring or placement process and understand that any release to a third party will not occur until that party has completed a certification regarding the use and viewing of confidential information. I agree to release, hold harmless, and indemnify TruDiligence from any liability, claims, demands, causes of action, damages, or expenses resulting from: any release of information to the Third Party pursuant to this authorization; the unauthorized use of this information by the Third Party; and, any actions taken by the Third Party pursuant to this authorization.
I understand that my date of birth is used solely as an identifier to avoid possible misidentification while completing the background check process. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as the original.

Signature

Date

Printed Name:

SSN:

[email protected]

Follow us on:

+1 (475) 296-3304