Employment Application - Pittsburgh #1 Home Care Agency

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Employment Application Form

ALKAS HOME CARE SERVICES LLC Provides equal employment opportunity to all employees and applicants for employment without regard to race, sex, color, national origin, ancestry, religious creed, disability, age and does not discriminate in the provision of any care or services to consumers based on any legally protected status.

Personal Information

First Name *

Middle Initial

Last Name *

Street Address *

Apartment, suite, etcE.g. Apt # 123

City *

State *

ZIP / Postal Code *

Phone *

Email Address *

Date of Birth *

Social Security Number *

Race

Lived in PA for more than 2 years? *YESNO

Position and Availability

Position Applied for *

Desired Wages/Salary *

Available to Start Working Date *

Days Available *All DaysSpecific Day/s

Available Day/s (Check all that apply) *SundayMondayTuesdayWednesdayThursdayFridaySaturday

Your available shift? *Day ShiftNight ShiftBoth Day and Night Shift

Type of Availability *Full-TimePart-TimeAs Needed

Do you Possess a Valid Driver’s License? *YESNO

Driver's License # *

State of License *

Expiration Date *

What are you going to use for your transportation? *

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

Do you have any issues working with clients who have pets? *YESNO

Have you ever applied here before? *YESNO

If YES, When?

Were you ever employed here? *YESNO

If YES, When?

How did you hear about us? *InternetFriendsAdsOther

Employment History (Start from Recent One)

Employment One:

Started Date *

End Date *

Name of the Employer *

Position *

Street Address *

City *

State *

ZIP / Postal Code *

Immediate supervisor name *

Employer Phone *

Summarization of work *

Reason for Leaving *

Starting Salary $

Ending Salary $

May we contact for Reference? *YESNO

Employment Two:

Started Date *

End Date *

Name of the Employer *

Position *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Immediate supervisor name *

Employer Phone *

Summarization of work *

Reason for Leaving *

Starting Salary $

Ending Salary $

May we contact for Reference? *YESNO

Formal Education and Skills

High School

Name

Location (City,State)

Year Graduated

College/University

Name

Location (City,State)

Year Graduated

Certification/Training

Name

Location (City,State)

Year Graduated

Note: If you have done certification courses then submit a copy of the certificate at the time of the interview.

Employment Authorization & Background Disclosure

Please answer the following questions as per your knowledge.

1. Are you legally authorized to work in the United States? *YESNO

2. Are you at least 18 years age? (If you are hired you may be required to submit proof of age.) *YESNO

3. Have you ever been terminated or compelled to resign from a job? *YESNO

4. Have you ever been convicted of a felony or misdemeanor? *YESNO

Occurrence Date: *

City *

State/Province

County

Explain the context *

Reference Verification Form

Who CANNOT Be Used as REFERENCE: Family members, anyone living in your household, friends, social acquaintances, or roommates.

Who CAN Be Used as Acceptable REFERENCE: Individuals who can speak to your reliability, professionalism, communication, judgment, and overall work skills such as former/current supervisor, manager, trainers, co-worker. volunteer or internship supervisors, religious leaders, teachers, or community program supervisors as your reference.

First Reference Information

Reference Full Name *

Reference's Phone *

Reference's Email

Second Reference Information

Reference Full Name *

Reference's Phone *

Reference's Email

Applicant’s Authorization to Release Information

Consent *

I certify that the reference I provided is not personal or household contact. I authorize the individual listed above to answer questions and to release all records of my employment, including performance evaluations, as requested by the above listed company in connection with my application for employment. I release my former employers from all liability for providing this information to Alkas Home Care Services, LLC.

Note: Please notify your reference that ALKAS Home Care Services, LLC, may contact them by phone or email so they can expect our outreach and respond promptly.

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.

Applicant Signature *

Please sign here

Date *