Employee Application - Pittsburgh #1 Home Care Agency

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Employment Application Form

Personal Information

First Name *

Middle Name

Last Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone *

Email Address *

Date of Birth *

GenderMaleFemaleOther

Race

Employee Status *SingleSeparatedMarriedDivorce

Position and Availability

How did you hear about us? *InternetFriendsAdsOther

Position Applied for *

Desired Wages/Salary *

Available to Start Working Date *

Days and Time (Availability) *SundayMondayTuesdayWednesdayThursdayFridaySaturday

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

What are you going to use for your transportation? *Personal automobilePublic TransportationCarpoolingI do not have means of transportation

Employment History

Employment – One (Start from your recent employment)

Started Date *

End Date *

Name of the Employer *

Employer Phone *

Street Address *

City

State/Province

ZIP / Postal Code

Position *

Immediate supervisor name

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 *

Employer Phone *

Street Address *

City

State/Province

ZIP / Postal Code

Position *

Immediate supervisor name

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

Degree Earned

College/University

Name

Location (City,State)

Year Graduated

Degree Earned

Certification/Training

Name

Location (City,State)

Year Graduated

Degree Earned

Note: Please submit a copy of the degree/certificate at the time of the interview.

An Employment Authorization

Please answer the following questions as per your knowledge.

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

Are you at least 18 years age? *YESNO

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

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

Occurrence Date: *

City *

State/Province

ZIP / Postal Code

Country

Explain the context *

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.

Signature *

Please sign here

Date *