Employment Application Form - Aken Home Health and Home Care

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APPLICATION FOR EMPLOYMENT

Aken Home Health and Home Care is an equal Opportunity Employer. Employment offers are made on basis of qualifications, and without regard of race, sex, religion, national or ethnic origin, disability, age, veteran status or sexual orientations.

Please complete this employment application form for consideration. We strongly suggest proof-reading your application before clicking the submit button. We look forward to working with you!

PERSONAL INFORMATION

First Name*

Middle Name

Last Name*

Other names Used

Date of Birth*

MM slash DD slash YYYY

Address*

City*

State / Province*

Postal / Zip Code*

Email Address*

Phone Number*

Are you legally entitled to work in the U.S.?*

Yes

Have you ever been convicted of a felony*

Yes

Please Explain

Are you 18 Years of age or older*

Yes

Current age

Are you currently employed?*

Yes

May we contact this employer?*

Yes

Company Name

Company Address

Current Job Title

Current Job Department

Have you ever been employed by Aken Home Health and Home Care?*

Yes

Date from

MM slash DD slash YYYY

Date To

MM slash DD slash YYYY

Reason for leaving

Are you related to any current Aken Home Health and Home Care?*

Yes

Their name

Their relationship to you

If required for position, do you have a valid Driver License?*

Yes

State issued, License # & Expiration date

If required for position, do you have a valid Proof of insurance*

Yes

Insurance Company & ID #

How did you learn about this employment opportunity at Aken Home Health and Home Care? Check all that apply*

Job Bulletin posting / walk

Depart. Of labor

Website

Referral by employee

Other

POSITION

Position Applying for*

LPN

CNA

HHA

CAREGIVER

DSP

Administration

Office | Clerical

Date Available*

MM slash DD slash YYYY

Applying For*

Part-Time

Full-Time

Temporary

Days

Evenings

Nights

Days Available to work*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?*

Yes

Please Explain

EDUCATION AND TRAINING

School Name

City | State

Dates Attended Month/Year (From)

Dates Attended Month/Year (To)

Did you Graduate?

If no, # of years left to graduate

Degree received

Major

click the + to add Education

Other credentials – Licenses | Certifications or professional affiliations, etc., which are relevant to the job(s) for which you are applying.

Type of License | certifications

License and | Certification # and State Issued

Expiration Date

Special Skills you have to offer for this position

EMPLOYMENT HISTORY (Begin with Most Recent Employment)

Employer #1 (Company Name)*

Job Title & Duties*

From*

MM slash DD slash YYYY

To*

Supervisor's Name*

Phone*

Address*

Reason for leaving

May We Contact This Employer?

Yes

Employer #2 (Company Name)

Job Title & Duties

From

MM slash DD slash YYYY

Supervisor's Name

Phone

Address

Reason for leaving

May We Contact This Employer?

Yes

Employer #3 (Company Name)

Job Title & Duties

From

MM slash DD slash YYYY

Supervisor's Name

Phone

Address

Reason for leaving

May We Contact This Employer?

Yes

REFERENCES: Give names of three Persons NOT related to you. Two of your References MUST be supervisory or Professional*

Name

Phone #

Address

Occupation

The information on this application is true, and accurate to the best of my knowledge.*

Full Name*

Signature

Date*

MM slash DD slash YYYY

APPLICATION DISCLAIMERS

Authorization to Release Information

I have applied for a position with Aken Home Care. I have been requested to provide information for their use in reviewing my background and qualifications. Therefore, I hereby authorize the investigation of my past and present work character, education, military and employment qualifications.

I authorize the release of my information to Aken Home Care whether the information is of record or not, and I do hereby release all persons, agencies, firms, companies, etc., from any damages resulting from providing such information.

This authorization is valid for 180 days from the date below. Please keep this copy of my release request in your files.

Signature

Name

Date

MM slash DD slash YYYY

Consent for Drug/ Alcohol Screen Testing

If you are offered and accept employment with Aken Home Care, in the interest of safety for all concerned, you will be required to take a urine test for drug and / or alcohol screening.

I have been fully informed of the reason for this urine test for drug and/or alcohol screening. I fully understand what I am being tested for, the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my potential employer and become part of my record.

If this test is positive and l am not hired. I understand that I will be given the opportunity to explain the results of this test.

I hereby authorize these test results to be released to:

Aken Home Care

Signature

Name

Date

MM slash DD slash YYYY

AKEN HOME CARE -IS AN EQUAL OPPORTUNITY EMPLOYER

Applicant Acknowledgement

I certify that the information in this application is accurate, current and complete. I understand that incorrect statements or omission may result in disqualification from further consideration or termination of employment.

I authorize Aken Home Care to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision.
I authorize Aken Home Care to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes.
I also authorize Aken Home Care to disclose any of my performance Appraisals, disciplinary record, or skills test for the same purpose as above.
I release Aken Home Care and any individual or entity providing information to Aken Home Care from all liability for any damages from the disclosure of this information.

I also understand and agree that:

Passing a medical examination and / or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated. I may not be hired, or if hired, employment may be terminated.
Subject to applicable state laws, Aken Home Care reserves the right to conduct drug screening and testing for reasonable suspicion at anytime during employment and as a pre-employment requirement. Any violation of this policy shall result in an applicant not being hired or an adverse employment action up to including immediate termination. Aken Home Care has the right to change this policy at any time as it requires.
I understand that nothing contained in this employment application or in granting of an interview creates an employment contract between Aken Home Care and me for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable at will", that I will have the right to terminate my employment at any time.
I understand that should I become employed by Aken Home Care my work assignment, schedules and / or work locations are subject to change according to the needs of the business and the clients of Aken Home Care.

Signature

Name

Date

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

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