Careers Form

* Required Information

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 back.
Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with Ready 2 Serve Home Health Care, an independently owned and operated company. 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

Today’s Date

Positions(s) Applied For *

Last Name *

First Name *

Middle Name

Date Of Birth *

Social Security Number *

Current Address

Street *

City *

State *

Zip Code *

Previous Address

Street *

City *

State *

Zip Code *

Home Phone *

Work Phone

Cell Phone *

Alternate Phone

Email Address *

Emergency Contact(s)

Name

Phone

Name

Phone

Valid Driver’s License Number

State Issued

Expiration Date

Make & Model of Vehicle

Year of vehicle

Auto In Co

Policy Number

Expiration Date

Have you ever submitted an application here before?

Yes

When?

Have you ever been employed here before?

Yes

When?

How did you hear about our Ready 2 Serve Home Healthcare LLC franchise?

Have you have been given a copy of the job description for the position for which you have applied to review?

Yes

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

Yes

Why are you interested in employment with us?

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

What date are you available to begin work?

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

SHIFT	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From:
To:

PREFERENCES

Please indicate location(s)

*In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required.

Are you willing to provide service to a client with a pet?

Yes

Which ones?

Cats

Dogs

Are you willing to provide service to a client that smokes?

Yes

JOB RELATED SKILLS

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

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?

What personal rewards do you get from working with seniors?

EDUCATION

Please select highest grade completed:

High School

City, State

Major/Subject

Number of Years Attended

Graduate

Yes

Vocational/Technical

City, State

Major/Subject

Number of Years Attended

Graduate

Yes

College/University

City, State

Major/Subject

Number of Years Attended

Graduate

Yes

*For employment our minimum education requirement is either a GED or High School diploma

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER

Are you currently working for this employer?

Yes

May we contact?

Yes

Company Name

City

State

Phone Number

Dates Employed: From

Job Title

Supervisor's Name

Duties

Salary

per

Reason for Leaving

SECOND MOST RECENT EMPLOYER

Company Name

City

State

Phone Number

Dates Employed: From

Job Title

Supervisor's Name

Duties

Salary

per

Reason for Leaving

THIRD MOST RECENT EMPLOYER

Company Name

City

State

Phone Number

Dates Employed: From

Job Title

Supervisor's Name

Duties

Salary

per

Reason for Leaving

SECURITY

Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.

As a condition of employment all employees must be “Bondable”& “Insurable”. Are you at least 19 years of age?

Yes

List states and counties of residence for the past seven years

Have you had any moving traffic violations?

Yes

Please describe

Have you been charged/convicted of a felony and/or misdemeanor/or served time?

Yes

Please describe

1) Incident

City/State

Charge

2) Incident

City/State

Charge

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

Yes

REFERENCES

We will contact these references, please notify them in advance.

1) Full Name

Phone Number

Best Time of Day to Call

Relationship

Number of Years Known

2) Full Name

Phone Number

Best Time of Day to Call

Relationship

Number of Years Known

3) Full Name

Phone Number

Best Time of Day to Call

Relationship

Number of Years Known

CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note on page one (1) 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. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Ready 2 Serve Home Healthcare LLC, and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

Applicant Name *

Date

Companionship	Housekeeping (dust/vacuum)	Errands/Shopping/Transportation
Meal Preparation	Laundry/Ironing	Personal Care
Activities (games/crafts)	Medication Reminders	Dementia/Alzheimer’s Care
Skilled nursing	Physical Therapy	Wound care