Date: 9/10/2010

Application Form

ABIDING HOMECARE

Abiding HomeCare (AHC) is an equal employment opportunity employer.  All employees have the right to work in a discrimination-free environment.  AHC will not permit or condone any arbitrary discrimination in the workplace.  It is our policy that all employment decisions will be made without regard to race, color, sex, sexual orientation, creed, religion, age, marital status, national origin, disability, honorably discharged veteran or military status, or any other basis prohibited by state, local, or federal laws.  Anyone with a protected disability will be reasonably accommodated as appropriate.

Your employment with Abiding Home Care, LLC is at-will, unless otherwise altered through a collective bargaining agreement or an individual contract that is in writing and signed by the Executive DIrector of Abiding HomeCare. You are free to resign at any time. Similarly, Abiding HomeCare is free to conclude the employment relationship at any time.

Personal Information
First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Emergency Contact
Number Question Effective Date Expiration Date
a Name (required)  
  N/A N/A
b Phone number (required)  
  N/A N/A
c Address (required)  
  N/A N/A
d Relationship (required)  
  N/A N/A

Section 2 - General
Number Question Effective Date Expiration Date
a Please enter today's date (required)  
  N/A N/A
b This is a part time position & actual hours are based on client needs & your availability. We provide services 24 hours a day, 7 days a week, & you will be required to work some evenings & weekends. Is this acceptable to you? (required)  
  N/A N/A
c Before a new employee starts work, we do background checks, personal reference checks, & a pre-employment drug screening, so it may be awhile before you start work. Is this acceptable to you? (required)  
  N/A N/A
d Are you a smoker? (required)  
  N/A N/A
e If question 2d is "Yes," can you work eight hours without smoking?  
  N/A N/A
f Do you have any allergies to household chemicals, perfume, or animals? If "yes," please explain in 2L below. (required)  
  N/A N/A
g Do you have internet access at home? (required)  
  N/A N/A
h Do you check your personal email daily? (required)  
  N/A N/A
i Why are you interested in working for Abiding HomeCare? (required)  
 
j Do you have a criminal record? (required)  
  N/A N/A
k If the answer to question 2j is "yes," please explain  
 
l Please provide additional details about any of the questions in section 2.  
 

Section 3 - Position
Number Question Effective Date Expiration Date
a I am applying for a position as a  
 
 
b Have you ever been convicted of a felony? (required)  
  N/A N/A
c If yes, please provide details  
 

Section 4 - Transportation
Number Question Effective Date Expiration Date
a Do you have a clear driving record? (required)  
  N/A N/A
b If question 4a is "No," please explain:  
 
c Do you have an insured, reliable vehicle? (required)  
  N/A N/A
d Make & model of vehicle  
  N/A N/A
e License plate number  
  N/A N/A
f Auto policy insurance number  
  N/A N/A
g Insurance company  
  N/A N/A
h Insurance agent's name  
  N/A N/A
i Insurance agent's telephone number  
  N/A N/A
j Current policy expiration date  
  N/A N/A

Section 5 - Preferences
Number Question Effective Date Expiration Date
a Number of hours you prefer to work each week (required)  
  (Numeric Answer Only) N/A N/A
b Times you prefer to work (required)  
  N/A N/A
c Any times you do NOT prefer to work  
  N/A N/A
d Can you be called at the last minute in case of emergency? (required)  
  N/A N/A
e Are you available to do live-in assignments for 1 to 3 consecutive days at a time? (required)  
  N/A N/A
f Additional comments  
 

Section 6 - Education
Number Question Effective Date Expiration Date
a What's your highest level of education completed? (required)  
 
 
 
b What degrees and/or certificates have you received?  
 
c What special skills do you have?  
 

Section 7 - Experience
Number Question Effective Date Expiration Date
a Describe any training or experience working with the elderly  
 
b What would you like most about working with the elderly? (required)  
 
c What would you like least about working with the elderly? (required)  
 
d Are you a good cook? (required)  
  N/A N/A
e If you answered "Yes" to question "7d," please describe the types of meals you're accustom to preparing.  
 

Section 8 - Skills. What tasks have you performed for seniors?
Number Question Effective Date Expiration Date
a Companionship?  
  N/A N/A
b Bathing/dressing?  
  N/A N/A
c Grooming?  
  N/A N/A
d Incontinence care?  
  N/A N/A
d Transfer assistance  
  N/A N/A
f Vacuuming?  
  N/A N/A
g Dusting?  
  N/A N/A
h Cleaned bathrooms?  
  N/A N/A
i Cleaned kitchen?  
  N/A N/A
j Changed bed linens?  
  N/A N/A
k Laundry?  
  N/A N/A
l Grocery shopping?  
  N/A N/A
m Cooking?  
  N/A N/A
n Driving?  
  N/A N/A
o Medication reminders?  
  N/A N/A

Section 9 - Employment History
Number Question Effective Date Expiration Date
a1 Current employer:  
  N/A N/A
a2 From:  
  N/A N/A
a3 To:  
  N/A N/A
a4 Job title:  
  N/A N/A
a5 Reason left:  
  N/A N/A
a6 Duties:  
 
b1 Previous employer:  
  N/A N/A
b2 From:  
  N/A N/A
b3 To:  
  N/A N/A
b4 Job title:  
  N/A N/A
b5 Reason left:  
  N/A N/A
b6 Duties:  
 
b7 Supervisor's name:  
  N/A N/A
b8 Supervisor's phone:  
  N/A N/A
c1 Please list information for any additional previous employers:  
 

Section 11 - Business References (employment, volunteer, etc)
Number Question Effective Date Expiration Date
a1 Name  
  N/A N/A
a2 Address  
  N/A N/A
a3 Relationship  
  N/A N/A
a4 Years known  
  (Numeric Answer Only) N/A N/A
a5 Telephone  
  N/A N/A
b1 Name  
  N/A N/A
b2 Address  
  N/A N/A
b3 Relationship  
  N/A N/A
b4 Years known  
  (Numeric Answer Only) N/A N/A
b5 Telephone  
  N/A N/A
c1 Name  
  N/A N/A
c2 Address  
  N/A N/A
c3 Relationship  
  N/A N/A
c4 Years known  
  (Numeric Answer Only) N/A N/A
c5 Telephone  
  N/A N/A

Section 12 - Personal References (minimum of three)
Number Question Effective Date Expiration Date
a1 Name (required)  
  N/A N/A
a2 Address  
  N/A N/A
a3 Relationship (required)  
  N/A N/A
a4 Years known (required)  
  (Numeric Answer Only) N/A N/A
a5 Telephone (required)  
  N/A N/A
b1 Name (required)  
  N/A N/A
b2 Address  
  N/A N/A
b3 Relationship (required)  
  N/A N/A
b4 Years known (required)  
  (Numeric Answer Only) N/A N/A
b5 Telephone (required)  
  N/A N/A
c1 Name (required)  
  N/A N/A
c2 Address  
  N/A N/A
c3 Relationship (required)  
  N/A N/A
c4 Years known (required)  
  (Numeric Answer Only) N/A N/A
c5 Telephone (required)  
  N/A N/A



CERTIFICATION AND RELEASE: I certify that I have read and understand the application note at the top 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 misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle 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 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.