Safe Harbor Care

In-Home Care Specialists

CONTACT INFORMATION
LAST NAME: / FIRST: / MIDDLE:
STREET ADDRESS: / EMAIL ADDRESS
CITY: / STATE: / ZIP CODE:
HOME PHONE: / CELL PHONE: / BUSINESS PHONE: / FAX NO:
WORK QUALIFICATIONS
ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S.A? / Yes / No
SOCIAL SECURITY NO.
DRIVERS LICENSE NO.
EXPIRATION DATES: / Health Card: / CPR Card:
HAVE YOU EVER BEEN CONVICTED OF OR CHARGED WITH A FELONY OR MISDEMEANOR? * / Yes / No
IF YES, GIVE DATE AND DETAILS:
Are you currently or have you in the past USED ILLEGAL DRUGS?
/ Yes / No

* Conviction of a crime is not an automatic bar to employment; other factors, such as the nature and date of the crime, will be taken into consideration.

WORK AVAILABILITY
WHEN ARE YOU AVAILABLE TO START? / WILL YOU WORK HOLIDAYS? / YES / NO
ARE YOU WANTING: / FULL TIME / PART TIME / HRS PER WK / LIVE IN
PLEASE INDICATE YOUR DAILY AVAILABILITY BY PLACING AN “X” ON THOSE DAYS AND TIMES YOU ARE AVAILABLE
MON / TUES / WED / THURS / FRI / SAT / SUN
DAYS / 8 AM ~ 4 PM
EVENINGS / 4 PM ~ 12 AM
NIGHTS / 12 AM ~ 8 AM
12 HR DAYS / 7 AM ~ 7 PM
12 HRS NIGHTS / 7 PM ~ 7 AM
ANYTIME YOU NEED ME
PREVIOUS Duties, Procedures, and Responsibilities
Duties / Yrs/Mons
ExpER / Duties / Yrs/Mons
ExpER / Duties / Yrs/Mons
ExpER / Duties / Yrs/Mons
ExpER
Companionship & Conversation / Grooming / Meal Planning & Preparation / Laundry and Linen
Bathing / Light Housecleaning / Running Errands / Incontinence Care
Dressing / Alzheimer’s & Dementia Care / Medication Reminders / Reloading a Feeding Tube
EDUCATION
Type of School / Name & Location / Major / Degrees Obtained & Date
High School
College
Other Education or Special Training
Certifications (X) / RN / LVN / MA / CNA / OTHER
Special Skills and Training
REFERRAL
Who referred you to our company?
Are you currently employed? / Yes / No
If so, may we make an inquiry of your present employer? / Yes / No
I Have Attached My Resume
MOST RECENT WORK EXPERIENCE
EMPLOYMENT DATES / LAST OR CURRENT POSITION
FROM / TO
EMPLOYER’S NAME / EMPLOYER’S PHONE
EMPLOYER’S MAILING ADDRESS / CITY / STATE / ZIP
TYPE OF BUSINESS / SUPERIOR’S NAME & TITLE
START PAY / END PAY / REASON FOR JOB CHANGE
DESCRIBE JOB DUTIES / RESPONSIBILITES:
PREVIOUS WORK EXPERIENCE
EMPLOYMENT DATES / LAST OR CURRENT POSITION
FROM / TO
EMPLOYER’S NAME / EMPLOYER’S PHONE
EMPLOYER’S MAILING ADDRESS / CITY / STATE / ZIP
TYPE OF BUSINESS / SUPERIOR’S NAME & TITLE
START PAY / END PAY / REASON FOR JOB CHANGE
DESCRIBE JOB DUTIES / RESPONSIBILITES:
ADDITIONAL WORK EXPERIENCE
EMPLOYMENT DATES / LAST OR CURRENT POSITION
FROM / TO
EMPLOYER’S NAME / EMPLOYER’S PHONE
EMPLOYER’S MAILING ADDRESS / CITY / STATE / ZIP
TYPE OF BUSINESS / SUPERIOR’S NAME & TITLE
START PAY / END PAY / REASON FOR JOB CHANGE
DESCRIBE JOB DUTIES / RESPONSIBILITES:
Personal References
Below, give the names of 3 persons you are not related to and you have known for at least 3 years.
NAME / ADDRESS / RELATIONSHIP / PHONE # / # YRS

I certify that the information on this application is correct and I understand that any misrepresentation or omission of any information will result in my disqualification from consideration for employment or, if employed, my dismissal. I understand that this is not a contract, offer, or promise of employment and that if hired, I can be terminated “at will”, with or without cause, with or without notice, at any time and for any reason, at the option of Safe Harbor Care or myself.

I further understand that no supervisor, manager, official of representative Safe Harbor Care and its related entities has the authority to enter into an employment contract or make any agreement, orally or in writing, contrary to the forgiving.

I have read, understand, and agree to this statement ______(please initial here).

Safe Harbor Care, in considering my application for employment, may verify the information set forth on this application, related papers or oral interviews and obtain additional background information relating to my background. I authorize all persons, schools, companies, corporations, law enforcement agencies and doctors to supply any information concerning my background that they may have whether or not it is on their records. I hereby release them and their company from all liability for divulging same. A photographic copy of this authorization shall be as valid as the original.

If any of my given information is found to be false or misleading, I understand that I will be subject to dismissal at any time during the period of my employment without liability for wages or salary except such as may have been earned at date of such termination and I agree to hold Safe Harbor Care and persons named herein blameless in that event.

I have read, understand, and agree to this statement ______(please initial here).

I understand that should I become employed by Safe Harbor Care my work assignment, schedule, and work locations are subject to change according to the needs of the business and the clients of Safe harbor Care.

I have read, understand, and agree to this statement ______(please initial here).

Safe Harbor Care is an equal opportunity employer and does not discriminate in its recruiting, selecting and hiring procedures because of race, color, gender, religion, national origin, age, sexual orientation or disability status nor does it discriminate with regard to Veteran status.

DATE: / SIGNED:

Pursuant to Title VII of the Civil Rights Act of 1964 (42 U.S.C. Et Seq) and 45 C.F.R. part 80, section 504 of the Rehabilitation At of 1973, as amended (29 U/S/C. 794) and 45 C.F.R. Part 84, and the Age Discrimination Act of 1975 (42 U/S/C/ 6101 Et Seq) and 45 C.F.R. Part 91, Safe Harbor Care adheres to an equal opportunity policy for all persons seeking admission as clients or seeking employment, and for all persons employed by the agency. Safe Harbor Care dose not discriminate because of age, race, color, religion, military status, marital status, gender preference, sex, national origin or disability.

You may mail this form to our corporate address:

Safe Harbor Care
1120 Nasa Parkway

Suite 405

Houston, Texas 77058

Or, you may fax this completed application to our corporate fax number:

Fax:281-333-2275

Alternately, you may email the completed application, as an attachment, to:

SHC NH-1200: Section 1 – 08-03-2013 PAGE 5 OF 4