Employement

Are you 18 years or older?

Yes No

Are you legally authorized to work in the US?

Yes No

Do you have reliable transportation?

Yes No

Do you have a car you can use for work?

Yes No

POSITION APPLYING FOR

Position

Desired Employment

Full-Time Part-Time Per-Diem Live-In

Date Available to Start:

Available Shifts

3. CERTIFICATIONS & SKILLS (Check all that apply)

CPR Expiration Date:

Skills

College / Vocational:

5. WORK HISTORY - Start with most recent (Last 3 jobs required)

May we contact?

Yes No

6. REFERENCES - 3 Professional References Required (Not family)

7. EMERGENCY CONTACT

8. BACKGROUND CHECK AUTHORIZATION - REQUIRED

I understand this position requires:

CORI (Criminal Offender Record Information) Check SORI (Sex Offender Registry) Check National Background Check Reference Checks Motor Vehicle Driving Record Check

Have you ever been convicted of a felony or misdemeanor?

Yes No

(Note: A conviction does not automatically disqualify you from employment.)I have read, understand, and agree to the above: Initials:

9. APPLICANT STATEMENT & SIGNATURE

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false statement or omission may result in disqualification from employment or termination if discovered after hire. I authorize Love Embrace All to verify all information and contact my references and former employers. I understand that employment at Love Embrace is at-will, meaning either the employee or employer may terminate employment at any time, with or without cause or notice. I authorize Love Embrace to conduct all necessary background checks as required for home care workers.

FOR OFFICE USE ONLY:

Documents Collected

ID License/Cert CPR Physical/TB

Care that moves with you

Employment Application Form

POSITION APPLYING FOR

3. CERTIFICATIONS & SKILLS (Check all that apply)

4. EDUCATION

5. WORK HISTORY - Start with most recent (Last 3 jobs required)

6. REFERENCES - 3 Professional References Required (Not family)

7. EMERGENCY CONTACT

8. BACKGROUND CHECK AUTHORIZATION - REQUIRED

9. APPLICANT STATEMENT & SIGNATURE

FOR OFFICE USE ONLY:

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