Employment freedom home health and hospice care service inc

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EMPLOYMENT APPLICATION

Freedom Home Health and Hospice Care Service Inc. 852159 9DthSSttrreeeett,- SMuaitreysBv,iMllea, rCyAsvi9ll5e9, 0C1A 95901

APPLICATION INSTRUCTIONS

If you need help filling out this application form or for any phase of the employment process, please notify the person that gave you this form and every effort will be made to accommodate your needs in a reasonable amount of time.

1. Please read "APPLICANT NOTE" below.

POSITION APPLIED FOR: ____________________________________________

TODAY'S DATE: ____________________________________________________

NAME: __________________________________________________________

LAST

FIRST

MI

2. Complete both side of this page. 3. If more space is needed to complete any question, use

comments section at the bottom of this page

MAIN PHONE:__________________WORK PHONE:______________________ EMAIL ADDRESS: __________________________________________________

4.

Print clearly: incomplete or illegible application will not be processed. PLEASE NOTE "NOT APPLICABLE" IF NOT

CURRENT ADDRESS:________________________________________________

ANWSERING A QUESTION

STREET

5. Provide only requested information. Failure to do so many

______________________________________________________

results in disqualification of your application. 6. Some packets may include an AFFIRMATIVE ACTION

QUESTIONNAIRE. This information is being gathered for

CITY

STATE

ZIP

PRIOR ADDRESS:___________________________________________________

affirmative action under Section 503 of Rehabilitation Act

STREET

of 1973. The information requested if voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete

___________________________________________________

CITY

STATE

ZIP

questionnaire.

EMERGENCY CONTACT:_____________________________________________

7. DO NOT FILL OUT ANY OTHER ATTACHED FORMS OR

NAME/RELATIONSHIP

PAGES UNTILL INSTRUCTED.

__________________________________________________

APPLICATION NOTE

TELEPHONE NUMBER

This application form is intended for use in evaluating your qualifications for employment. 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 are grounds for

terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without

discrimination based on sex, marital status, race, color, age, creed, national original, sexual orientation, military service membership, ancestry, religion, height, weight,

use of guide or support animal because of blindness deafness or physical handicap or presence of disabilities. A conviction will not necessarily bar an application from

employment. Additional testing of job-related skills and for the presence of drugs in your body maybe required prior to employment. After an offer of employment, and

prior reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a

medical history form and may be required to be examined by a medical professional designed by the company.

AVAILABILITY

What date can you start?_______________ What category would you prefer?

Full Time

Part Time

Temporary

Per Diem

For which schedules are you available?* Weekdays

Weekends Evenings Nights Overtime Shifts Other _________

*reasonable efforts will be made to accommodate sincerely held moral and ethical beliefs, (WI) religious beliefs and practices (all other states)

JOB RELATED SKILLS

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

SECURITY

NOTE: Do not fill out any part of this section you believe to be non-job related

If the job requires, do you have the appropriate valid driver's license? Name on license_____________________ DL#_____________ Type________ State of Issue_____ Have you had any moving violations within the last seven years? Please describe.______________ Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company.______________________________________________________ Have you been given a job description or had the essential functions of the job explained to you? Do you understand these essential functions? Can you perform the essential functions of this job with or without reasonable accommodation?

List states and counties of residence for the past seven Years:____________________________

Yes

No

Yes

No

Have you used any names or Social Security Numbers other than given above? If so, please list it in a sepHaarvaeteysohueueste. d any names or Social Security Numbers other than given above? If so, please list it

Yes

No

Yes

No

Haivneaysoeupbaeraetnecsohneveitc.ted of a crime in the past seven years? If so, please describe in detail on a sepHaarvaeteysohuebeet.eAnpcpolnicvaicntteids noof taocbrilmigaetiendtthoedpiascstlosseevaenyyreeafresr?eInfcseo,toplaeapsree doerspcorisbtetrinialddeitvaeilrsoinona prosgerpaamra,taensyhceoent.vAicptipolnicawnhticishnhoatsobbeliegnatseedalteodd, eisxcplousnegaendyorreeferaresendcebtyothaepcreouorrt,pors,titfrCiaallifornia, any

madrivjuearsniaonreplarotegdrammi,sdaenmy ceoanvoirctcioonnvwichtiicohnheanstebreeednmseoarleedth, aenxptuwnogeyedaorrs epraiosredtobtyhtehdeactoeuorft,tohris, if

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wilslubcehraesviaegwesa.)t time of offense, remoteness of the offense, time since last conviction, nature of

(ASK FOR AN ADDITIONAL PAGE IF NECESSARY)_________________________________________________________

COMM_E_N__T_S___________________________________________________________________________________________________

PREVIOUS EMPLOYERS

PLEASE NOTE: Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for a phone book or call information if necessary. FOR WMPLOYERS OUTSIDE THE U.S., A CURRENT FAX NUMBER IS MANDITORY.

MOST RECENT EMPLOYER

Yes No Yes No

Are you currently working for this employer? If yes, may we contact?

PHONE ( )

___________________________

COMPANY NAME

________________________

CITY

_______

STATE

FAX ( )

___________________________

_________________________ _______________________________

DATE EMPLOYED

JOB TITLE

SUPERVISORS NAME

______________________________________________________________________________________________

DUTIES

_____________________________________

___________________________________________________

(HOUR,WEEK,MONTH)

REASON FOR LEAVING

SECCOND MOST RECENT EMPLOYER

___________________________

_________________________

PHONE ( ) _______

COMPANY NAME

___________________________

CITY

_________________________

_S_TA_T_E_______F_A__X____(____) __________

DATE EMPLOYED

JOB TITLE

SUPERVISOR NAME

_______________________________________________________________________________________________

DUTIES

_________________________________________ __________________________________________________

(HOUR,WEEK,MONTH)

REASON FOR LEAVING

THIRD MOST RECENT EMPLOYER ____________________________

__________________________

PHONE ( ) _______

COMPANY NAME

____________________________

CITY

_________________________

S_T_A_TE____F_A_X_____( ___)__________

DATE EMPLOYED

JOB TITLE

SUPERVISORS NAME

_________________________________________________________________________________________________

DUTIES

_______________________________________ _____________________________________________________

(HOUR,WEEK,MONTH)

REASON FOR LEAVING

REFERENCES

Include only individuals familiar with your work ability. Do not include relatives or name of supervisors listed above

NAME 1. 2.

EDUCATION

NAME HIGH SCHOOL

ADDRESS / PHONE

YEARS KNOWN / RELATIONSHIP

NOTE: Do not fill out any part of this section you believe to be non-job related.

Please circle highest grade completed. 7 8 9 10 11 12 13 14 15 16+

If your school records are under a different name than listed on page 1, please enter that name:____________

CITY / STATE

GRADUATED

DEGREE TYPE

YES NO

COLLEGE

YES NO

OTHER

YES NO

CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note on page one 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, omission or misinterpretation of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. I authorize the company and/ or its agents, including any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit drug testing to detect the use of illegal drugs prior to during employment.

SIGNATURE:______________________________________________________________________________________________DATE:__________________________________

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