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Homecare Careers Application

Please fill out the following application.  You may attach a copy of your resume at the end.

EMPLOYMENT APPLICATION

Today's Date *
Position Desired *
Date Available *
First Name *
Middle Name
Last Name *
Driver's License #
Street Address *
City, State, Zip *
Phone # *
Cell Phone # *
Email Address *
Emergency Contact *
Phone # *
Cell Phone # *
Are you eligible to work in the U.S.? * YesNo
Resident Alien #
Are you willing to work any shift? * YesNo
If no, list your days and hours of availability:
Are you willing to work weekends? * YesNo
Are you willing to work holidays? * YesNo
HOME HEALTH COMPANIONS POLICY IS TO OBTAIN CRIMINAL BACKGROUND CHECKS ON ALL EMPLOYEES. YOU WILL NOT BE DENIED EMPLOYMENT SOLELY BECAUSE OF A CONVICTION RECORD UNLESS THE OFFENSE IS RELATED TO THE JOB FOR WHICH YOU ARE APPLYING.
Have you ever been convicted of a felony or misdemeanor? * YesNo
If yes, please state when and where and the nature of the offense:
Are you a veteran of the U.S. Military? * YesNo
If yes, were you honorably discharged? * YesNo
Do you have any specialized training applicable to employment at Home Health Companions? * YesNo
If yes, please explain:
Please state why you would like to work for Home Health Companions:

EDUCATION AND TRAINING

High School *
Name
Address
# of Years Attended
Graduated? YesNo
Type of Degree
College
Name
Address
# of Years Attended
Graduated? YesNo
Type of Degree
Nursing School
Name
Address
# of Years Attended
Graduated? YesNo
Type of Degree
Other
Name
Address
# of Years Attended
Graduated? YesNo
Type of Degree

Work History

(start with most recent job)
Job 1
Employer's Name
Position
Address
Phone #
Dates of Employment (start-end)
Pay Rate
Supervisor's Name
Reason for Leaving
Okay to Check Reference? YesNo
Job 2
Employer's Name
Position
Address
Phone #
Dates of Employment (start-end)
Pay Rate
Supervisor's Name
Reason for Leaving
Okay to Check Reference? YesNo
Job 3
Employer's Name
Position
Address
Phone #
Dates of Employment (start-end)
Pay Rate
Supervisor's Name
Reason for Leaving
Okay to Check Reference? YesNo

References

(list three, no former employers or relatives)
Reference 1 *
Name
Profession
Phone* #
Reference 2 *
Name
Profession
Phone #
Reference 3 *
Name
Profession
Phone #

PROFESSIONAL LICENSE INFORMATION

Do you have a valid professional license, registration, or certification in Texas? YesNo
Do you have a valid professional license, registration, or certification in Texas? If yes, please explain:
PLEASE NOTE: This does not refer to your driver's license.
Professional license, registration, or certification number:*
Have you been licensed in another state?* YesNo
Has disciplinary action ever been taken against your license?* YesNo
If yes, please explain:
Has your license ever been revoked?* YesNo
If yes, please explain:
Are you CPR certified?* YesNo

EMPLOYMENT ACKNOWLEDGMENT

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED WITHIN THIS APPLICATION IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THE MISREPRESENTATION OF FACTS WILL BE CAUSE FOR REJECTION OF THIS APPLICATION OR IMMEDIATE DISMISSAL FROM EMPLOYMENT.

FURTHERMORE, I GIVE PERMISSION TO CONTACT FORMER EMPLOYERS, ASSOCIATES, AND SCHOOLS TO DETERMINE EMPLOYMENT ELIGIBILITY. I ALSO RELEASE HOME HEALTH COMPANIONS, FORMER EMPLOYERS, ASSOCIATES, AND SCHOOLS FROM ALL LIABILITY FOR FURNISHING REQUESTED INFORMATION. I ALSO AGREE TO WAIVE MY RIGHT TO RECEIVE WRITTEN NOTICE OF ANY INFORMATION PROVIDED.

I UNDERSTAND MY EMPLOYMENT RELATIONSHIP IS AT WILL AND THAT AS AN AT WILL EMPLOYEE I HAVE THE RIGHT TO TERMINATE MY EMPLOYMENT WITH OR WITHOUT NOTICE AND WITH OR WITHOUT CAUSE. I ALSO UNDERSTAND THAT HOME HEALTH COMPANIONS RETAINS THE SAME RIGHT TO TERMINATE MY EMPLOYMENT WITH OR WITHOUT CAUSE OR NOTICE.

I UNDERSTAND THAT AS A CONDITION OF EMPLOYMENT I AGREE NOT TO COMMENCE ANY ACTION OR SUIT RELATING TO MY EMPLOYMENT RELATIONSHIP WITH HOME HEALTH COMPANIONS, BEYOND SIX (6) MONTHS (180 CALENDAR DAYS) AFTER THE DATE OF THE EVENT OR THE DATE OF TERMINATION OF EMPLOYMENT. I ALSO AGREE TO WAIVE ANY STATUTE OF LIMITATION TO THE CONTRARY.

I UNDERSTAND THAT THIS APPLICATION WILL REMAIN ACTIVE FOR CONSIDERATION FOR SIX (6) MONTHS (180 DAYS). IF AT THE CONCLUSION OF THIS PERIOD, I WANT HOME HEALTH COMPANIONS TO CONTINUE TO CONSIDER ME FOR EMPLOYMENT, I MUST REAPPLY.

I UNDERSTAND THAT DRIVING A VEHICLE MAY BE A REQUIREMENT OF THIS POSITION AND IF A REQUIREMENT, I UNDERSTAND IF AT ANY TIME I AM UNABLE TO LEGALLY DRIVE A VEHICLE, OR IF I AM UNABLE TO BE INSURED, THAT, HOME HEALTH COMPANIONS, HAS THE RIGHT TO TERMINATE MY EMPLOYMENT. I ALSO AGREE TO IMMEDIATELY (WITHIN 24 HOURS) NOTIFY MANAGEMENT WHEN I HAVE A MOVING VIOLATION OR AM INVOLVED IN A VEHICLE ACCIDENT, WHETHER ON MY TIME OR COMPANY TIME.

I UNDERSTAND AND AGREE HOME HEALTH COMPANIONS, MAY REQUIRE A PHYSICAL EXAMINATION AND DRUG SCREENING AT ANY TIME. IF REQUESTED, EMPLOYMENT IS CONTIGENT UPON PASSING A PHYSICAL EXAMINATION AND/OR DRUG SCREENING. I AGREE THIS APPLICATION IS THE PROPERTY OF HOME HEALTH COMPANIONS,., THAT I HAVE NO RIGHT TO INFORMATION CONTAINED HEREIN, AND AT NO TIME WILL THIS APPLICATION BE RETURNED TO ME.

I UNDERSTAND THAT AS A CONDITION OF EMPLOYMENT I AGREE TO COMPLY WITH HOME HEALTH COMPANIONS' EMPLOYEE POLICIES AND WORK RULES.

Resume

Attach your resume.

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