Application Form

INSTRUCTIONS: If you need help filling out this online application form, please notify the person who gave you the form. Every effort will be made to meet your needs in a reasonable amount of time to address your questions about any phase of the staffing process.

Complete all required sections of this application.
Incomplete applications are not acceptable.
The application will be valid for 60 days.

ONLINE APPLICATION FORM

Today's Date: *

PERSONAL INFORMATION

Name *

First

Middle

Last

Current Address: *

Address Line 1

City

State

Zip Code

Previous Address:

Address Line 1

City

State

Zip Code

Home Phone: *

Cell Phone:

Work Phone:

Alternate Phone:

Email Address: *

Confirm Email

Emergency Contact #1: *

First

Last

Phone: *

Emergency Contact #2:

First

Last

Phone:

Valid Driver’s License #: *

State Issued: *

Expiration Date: *

Make & Model of Vehicle:

Year of vehicle:

Auto Insurance Company:

Policy Number:

Expiration Date:

Have you ever filed an application with us before? *

Have you ever been employed with our organization before? *

Have you have been given a copy of the job description for the position for which you have applied to review? *

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? *

Why are you interested in employment with us?

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

What date are you available to begin work? *

PREFERENCES

Please indicate the types of services which you are willing to provide: *

*In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required.

Are you willing to provide service to a client with a pet? *

Are you willing to provide service to a client that smokes? *

JOB RELATED SKILLS

Describe any training or life skills you have that apply to caring for a senior:

Describe any work history you have that would apply to caring for a senior:

What do you like (or think you would like) most about working with older adults?

What do you like (or think you would like) least about working with older adults?

What personal rewards do you get from working with seniors?

EDUCATION

Please check highest grade completed:

Grade School:

High School:

HIGH SCHOOL OR EQUIVALENT:

School Name:

School Address:

Course of Study:

Number of Years Attended:

Did you graduate? *

Yes
No
GED Received

VOCATIONAL OR TECHNICAL SCHOOL EDUCATION:

Did you attend vocational or technical school? *

COLLEGE EDUCATION:

Did you attend college?

Did you attend graduate school?

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential. Please list by most recent employer.

MOST RECENT EMPLOYER

Company Name: *

Company Address: *

Address Line 1

City

State

Zip Code

Phone: *

Supervisor Name: *

Job Title: *

Dates Employed: *

From Date - To Date/Present

Duties: *

Salary: *

Frequency of Salary:

Reason for Leaving: *

Are you currently working for this employer? *

SECOND MOST RECENT EMPLOYER

Company Name:

Company Address:

Address Line 1

City

State

Zip Code

Phone:

Supervisor Name:

Job Title:

Dates Employed:

From Date - To Date

Duties:

Salary:

Frequency of Salary:

Reason for Leaving:

THIRD MOST RECENT EMPLOYER

Company Name:

Company Address:

Address Line 1

City

State

Zip Code

Phone:

Supervisor Name:

Job Title:

Dates Employed:

From Date - To Date

Duties:

Salary:

Frequency of Salary:

Reason for Leaving:

SECURITY

Please be sure to complete the attached Authorization to do a criminal and/or motor vehicle background check.

As a condition of employment all employees must be “Bondable”& “Insurable”. Are you at least 19 years of age? *

List states and counties of residence for the past seven years: *

Have you had any moving traffic violations? *

Have you been charged/convicted of a felony and/or misdemeanor/or served time ? *

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? *

REFERENCES

Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional references. DO NOT INCLUDE RELATIVES.

Full Name:

Reference #1

Home Phone:

Work (Other) Phone:

Full Name:

Reference #2

Home Phone:

Work (Other) Phone:

Full Name:

Reference #3

Home Phone:

Work (Other) Phone:

DOCUMENT UPLOAD

Please attach any additional information you feel may be helpful to us in considering your application.
Max File Size 8MB.

File Upload

Click or drag a file to this area to upload.

File Upload

Click or drag a file to this area to upload.

File Upload

Click or drag a file to this area to upload.

File Upload

Click or drag a file to this area to upload.

CERTIFICATION AND RELEASE:

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and/or motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Ideal Healthcare Solutions,LLC, and myself is terminable atwill, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

Applicant Electronic Signature: *

First

Middle

Last

This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form(s) are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

Date: *

Name

CLICK BELOW TO SEE IF YOU QUALIFY!

ONLINE APPLICATION FORM

PERSONAL INFORMATION

AVAILABILITY

PREFERENCES

JOB RELATED SKILLS

EDUCATION

WORK HISTORY

SECURITY

REFERENCES

DOCUMENT UPLOAD

CERTIFICATION AND RELEASE: