Employment Application







    Please complete all fields. If a field doesn’t apply to you, please indicate ‘N/A’.

    Name :
    Date:
    Preferred Name:

    Email:
    Address:
    Phone Number:
    Cell Phone Number:
    Social Security# (last 4 digits only):
    XXX

    XX

    Referred By:
    Emergency Contact #1
    Emergency Contact #2
    Position Desired:
    Date You Can Start:
    Are you eligible to work in the United States?
    YesNo
    Are you 18 years of age or older?
    Date Of Birth
    Do you have a valid driver’s license?
    YesNo
    Valid car insurance?
    YesNo
    Car registration?
    YesNo
    Do you have reliable transportation?
    YesNo
    Available to work a minimum of 6-8 hours/day?

    EDUCATION AND TRAINING

    School
    Location
    Highest grade completed
    Dates Attended
    Degree/ certificate

    CHHA TRAINING

    Location
    Dates of training:
    Are you licensed or certified?
    YesNo
    If yes, please select the type of license or certificate held:
    License/certificate number:
    Expiration date:
    Issued by:
    Have you ever had your license or certificate revoked or suspended or disciplinary action taken against it?
    If yes, please explain:
    Are you CPR certified?
    If yes, date issued
    Expiration date:
    List any additional skills, relevant to this position
    Do you have malpractice insurance?
    If yes, policy #:
    Name and address of insurance carrier:
    Expiration date:

    WORK EXPERIENCE

    Indicate your work history, beginning with your most recent employer. Explain gaps in employment. FAVOR SENIOR HOME CARE LLC reserves the right to
    contact all current and former employers for reference information.
    Employer :
    Address:
    Supervisor/title:
    Phone:
    Email:
    Position Title:
    Dates of Employment From:
    To
    Work experience/title/department:
    Reason for Leaving:
    Employer :
    Address:
    Supervisor/title:
    Phone:
    Email:
    Position Title:
    Dates of Employment From:
    To
    Work experience/title/department:
    Reason for Leaving:
    Employer :
    Address:
    Supervisor/title:
    Phone:
    Email:
    Position Title:
    Dates of Employment From:
    To
    Work experience/title/department:
    Reason for Leaving:
    Employer :
    Address:
    Supervisor/title:
    Phone:
    Email:
    Position Title:
    Dates of Employment From:
    To
    Work experience/title/department:
    Reason for Leaving:

    REFERENCES

    Character/Professional References: Name
    Address
    Phone Number
    List any volunteer positions, relevant to this position

    PLEASE READ CAREFULLY

    I, , hereby authorize FAVOR SENIOR HOME CARE LLC to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination,including the reasons for such termination.

    I certify that information contained in this application is true and complete. I understand that false information may be grounds for disqualification for employment or for immediate termination of employment in the future if I am hired. I authorize FAVOR SENIOR HOME CARE LLC to investigate and verify all information on this application and release from all liability or responsibility for damages all persons, companies or corporations supplying this information.I understand that all references listed above may be contacted in addition to past employers and educational institutions.

    I understand that if hired, employment will be AT WILL, meaning employment can be terminated without notice by FAVOR SENIOR HOME CARE LLC or me at any time or for any reason. I understand this application is not a contract or guarantee of employment. I understand that if offered employment, it shall be contingent upon meeting the health requirements of the agency, completing the Agency Orientation program, demonstrating competency skills, completing the Employment Verification Form (I-9), satisfactory proof of employment authorization and identity, and a clear criminal background check.I understand that FAVOR SENIOR HOME CARE LLC reserves the right to conduct random drug and alcohol screening(s), motor vehicle driving record check(s)
    at any time prior to or during employment. I agree to have my picture taken for identification purposes. I authorize FAVOR SENIOR HOME CARE LLC to conduct a criminal background check.

    I understand the agency is an Equal Opportunity Employer.