A Touch of Home

Caregiver application for  employment

A Touch of Home is an equal opportunity employer dedicated to a policy of non-discrimination on any basis including race, colour, age, sex, religion, disability, national origin or marital status.

Full Name (First/Last)	*
Address	*
City / State / Zip	*	*- - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY *
Telephone	*	Social Security Number*
Emergency Contact Information
Contact Name	*	Relationship*
Contact Phone	*
Contact Address	*
Contact City / State / Zip	*	*- - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY *
Application Information
I am applying for a postion as	*	Caregiver Office Staff
Have you ever been convicted of any felony or misdemeanor?	*	No Yes
If yes, details must be provided here
Transportation Some caregiving positions require either a car or valid driver’s license, including current and valid insurance coverage.
Do you have an automobile?	*	Yes No
Make/Model
License Plate Number		State- - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Driver's License Number
Insurance Company
Hours Desired	*
Are you available for 24 hr live-in position?	*	No Yes 3 Days 4 Days 5 Days
Education
High School		City/State Dates
College		City/State Dates
Other		City/State Dates
Degrees/Certificates
Special Skills/Training
Names, addresses, telphone numbers for any non-profit, volunteer organizations affiliated with
Work Experience Please list your work experience for the past five years beginning with the most recent job held. If you were self employed, give firm name. Attach additional sheet if necessary.
May we contact your current employer to verify your employment history?	*	Yes No
Company
Start
End
Job Title
Reason for leaving (be specific)
List the duties you performed, skills used or learned, advancement or promotion while you worked at this company
Supervisor
Phone
Company
Start
End
Job Title
Reason for leaving (be specific)
List the duties you performed, skills used or learned, advancement or promotion while you worked at this company
Supervisor
Phone
Are you a legal citizen of the United States of America?	*	Yes No
Certification and Release: I certify the above stated and indicated are true in fact an no misrepresentation of myself has been made. I understand that any false information, omissions or misrespesentation of facts will result in rejection of this application and/or discharge at any time during employment. I authorize A Touch of Home to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies & law enforcement authorities to release any information concerning my background & hereby release any said persons, schools, companies & 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 and that I am willing to submit a drug testing at any time to detect the use of illegal drugs prior to or during employment. Restrictive Covenant: I agree not to do business directly with any individual or business entity that A Touch of Home has introduced to me or by entering into employment with such individuals or businesses.
Applicant's Signature	*
Date	*