HOME INSTEAD SENIOR CARE
21 Yost Boulevard, Suite 400
Pittsburgh, PA 15221
412-646-1257
PLEASE READ THE FOLLOWING
BEFORE COMPLETING OUR APPLICATION
JOB APPLICATION INSTRUCTIONS:
1. There is no guarantee of a job offer or a job interview in completing our application. Your application will be considered with others who have submitted applications. Decisions about interviews will be based on this comparison.
2. Our application must be completely filled out. The information must be accurate and true in order for you to be considered for employment.
3. If the information provided on our application cannot be satisfactorily verified by employment reference checks, your application could be considered incomplete.
4. Due to the large number of applications we received and the competitive nature of our employment process, specific reasons for non-employment decisions will not be released.
5. By completing our application, you will be subject to the following background checks:
Employment Reference Checks from Former Employers
Personal Reference Checks (No Relatives)
Criminal Record Check
I, ______, have read and understand the above statements.
Date: ______
RELEASE AUTHORIZATION
Name:______
(Last) (First) (Middle Initial)
Maiden/Previous Name(s): ______
Home Address: ______
______
______
(City) (State) (Zip Code)
Social Security Number: ______Date of Birth: ______
Driver’s License Number: ______State Issuing: ______
Authorization to Secure Consumer Investigative Report
I authorize Home Instead Senior Care to make whatever inquiries it may deem necessary in connection with my application of employment. As part of such inquiries, Home Instead Senior Care has my permission to contact persons who may have information regarding my suitability for employment and to secure consumer reports (including investigative consumer reports).
I authorize instruct any person or agency contacted to participate or conduct inquiries at the request of Home Instead Senior Care, to compile information, and to furnish any information obtained as a result of such inquiries.
I further authorize Home Instead Senior Care in its sole discretion, to furnish copies of this authorization and my application to any person and/or consumer-reporting agency in connection with above purposes.
Authorization for Drug Screening
I consent to drug testing designed to detect the presence of alcohol or the illegal use of drugs.
Disclosure Statement
Information contained in reports obtained by Home Instead Senior Care in accordance with above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that Home Instead Senior Care completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing to the personnel department within a reasonable period of time after your application for employment is received.
I hereby acknowledge that I have read the above disclosure statement and have understood it.
______
(Signature) (Date)
EMPLOYMENT APPLICATION
HOME INSTEAD SENIOR CARE
21 Yost Boulevard, Suite 400
Pittsburgh, PA 15221
412-646-1257 Phone 412-774-1744 FAX
INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.
Please read "Applicant Note” below.
Complete all pages pf this application.
Print clearly. Incomplete or illegible applications may not be accepted.
If more space is needed to complete any question, use comments section on the last page.
Application will be valid for 60 days.
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead Senior Care franchise. 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 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.
PERSONAL INFORMATION
Social Security Number: ______-______-______Today’s Date: ______
Name: ______
Last First Middle
Current Address: ______
Street City State Zip Code
Home Phone: (______) ______Work Phone: (______) ______
Alternate/Cell Phone: (______) ______Email Address: ______
Valid Driver’s License #:______State Issued:______Exp Date:______
Other Names or Social Security Numbers Previously Used:
______
Last First Middle Social Security Number
______
Last First Middle Social Security Number
Previous Address: ______
Street City State Zip Code
Emergency Contact(s): ______(______) ______
Name Phone
Have you ever submitted an application here before? Yes / No If yes, when? ______
Have you ever been employed here before? Yes / No If yes, when? ______
How did you hear about our Home Instead Senior Care franchise office? ______
AVAILABILITY & PREFERENCES
Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.
When can you begin work? ______Approximately how many hours per week do you wish to work? ______
Please indicate the days and times that you are available to work:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Start: ______
End: ______
Please indicate the types of services, which you are willing to provide:
Companionship / Housekeeping (dust/vacuum) / Errands/ShoppingMeal Preparation / Laundry/Ironing / Dressing Assistance
Walking/Standing Assistance / Transportation / Dementia/Alzheimer’s Care
Toileting/Incontinence Care / Bathing Assistance
Are you willing to provide service to a client with a pet? Yes / No If yes, which ones: ___Cats ___Dogs
Are you willing to provide service to a client that smokes? Yes / No
Do you own a working vehicle? Yes / No
Have you had a TB Test in the past 12 months? Yes / No
Have you had a physical in the past 2 years? Yes / No
Are you currently certified in First Aid? Yes / No CPR? Yes / No
JOB RELATED SKILLS
You have been given a copy of the job description for the position for which you have applied. Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? Yes / No
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: ______
______
EDUCATION
Please circle highest grade completed:
Grade School: 6 7 8 High School: 9 10 11 12 College: 13 14 15 16 16+
School Type / School Name / City, State / Major/Subject / # Yrs. Attended / GraduateHigh School / Y / N
Vocational / Y / N
College/University / Y / N
Other / Y / N
WORK HISTORY
Your application will not be considered unless all questions in this section are answered.
Since we will contact previous employers, the correct telephone numbers of past employers are essential.
MOST RECENT EMPLOYER
Are you currently working for this employer? Yes / No If yes, may we contact? Yes / No
______( _____ )______
Company Name City State Phone Number
Dates Employed: From ______to ______
Job Title Supervisor's Name
______
Duties
$______per ______
Salary (Hour, Week, Month) Reason for Leaving
Additional professional reference employed by this employer:
Name: ______Phone: (_____)______
Last First
SECOND MOST RECENT EMPLOYER
______( _____ )______
Company Name City State Phone Number
Dates Employed: From ______to ______
Job Title Supervisor's Name
______
Duties
$______per ______
Salary (Hour, Week, Month) Reason for Leaving
Additional professional reference employed by this employer:
Name: ______Phone: (_____)______
Last First
THIRD MOST RECENT EMPLOYER
______( _____ )______
Company Name City State Phone Number
Dates Employed: From ______to ______
Job Title Supervisor's Name
______
Duties
$______per ______
Salary (Hour, Week, Month) Reason for Leaving
Additional professional reference employed by this employer:
Name: ______Phone: (_____)______
Last First
BACKGROUND
As a condition of employment all employees must be “Bondable”. Have you lived within the state of Pennsylvania for the past 2 consecutive years? Yes / No
List states and counties of residence for the past seven (7) years: ______
Have you had any moving traffic violations? Yes / No If yes, please describe: ______
Have you been convicted of a felony or misdemeanor in the past seven (7) years? Yes / No If yes, please describe:
Incident City/State Result
______
PERSONAL REFERENCES
(Do not include relatives)
Please provide contact information for three personal references, none of whom are related to you or that you have known for less than three years. Your application will not be considered unless six references (3 personal, and 3 professional listed on the previous page) are provided here and on the previous page respectively. Please notify these references in advance.
Full Name / Phone Number / Best Time of Day to Call / Relationship / Number of Years Known1) / H ( )
W ( ) / AM / PM
AM / PM
2) / H ( )
W ( ) / AM / PM
AM / PM
3) / H ( )
W ( ) / AM / PM
AM / PM
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, 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 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. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND K-6 CORPORATION D.B.A. HOME ISNTEAD SENIOR CARE IS TERMINABLE AT-WILL, SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING.
______
APPLICANT SIGNATURE DATE
“K-6 Corporation, d.b.a. an independently owned and operated Home Instead Senior Care franchise”.
SUPPLEMENTARY QUESTIONS
Please respond to these short answer questions.
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? ______
Think about a time when your job required you to perform a task that you didn't know how to do. How did you respond?
______
What do you expect from your employer? ______
If you were hiring someone to take care of a valued family member, what would you look for? ______
Describe a conflict you've had with a colleague or a client and how you resolved it. ______
Why will you make a quality CAREgiver?
______
______
Comments:______
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