Application for Employment - Apply Now - Companions & Homemakers Inc.

EMPLOYMENT HISTORY & WORK REFERENCES

Current or most recent Employer

From

Employer/Client Name

Phone

City

State

Job Title

Supervisor

Describe Your Duties

Reason You Left

Previous Employer

From

Employer/Client Name

Phone

City

State

Job Title

Supervisor

Describe Your Duties

Reason You Left

Next Previous Employer

From

Employer/Client Name

Phone

City

State

Job Title

Supervisor

Describe Your Duties

Reason You Left

Explain any gaps of employment over 6 months

If you were you referred to us by a current Companions & Homemakers caregiver please give their name

Are you eligible to work in the U.S.?

Yes No

(All new hires will be required to provide proof of eligibility to work in the U.S.)

Are you 18 or older?

Yes No

Car Available?

Yes No

Desired Number of Hours Per Week

Availability

Please place a checkmark in every time period of each day you are available to work for us.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

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

Yes No

If No, please explain

When would you be available to begin work?

Type of employment desired

Full Time Part Time

Hourly rate/salary desired?

EDUCATION

High School/Technical School

Location

College

Location

Other Training/Education

Location

EMERGENCY CONTACT

Emergency Contact Name

Phone #

BACKGROUND AND CERTIFICATION

1. How did you hear of Companions & Homemakers?

2. Have you ever cared for an elderly or disabled person? Please explain

3. Have you ever worked for Companions & Homemakers, Inc. before?

Yes no

If yes, when?

What branch?

Supervisor's Name

4. Have you ever been discharged by a prior employer?

Yes no

If yes, please state name of employer and the reason

5. Have you ever been convicted of a crime in any state?

Yes no

If you answered yes, please provide additional information below

6. Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?

Yes no

If you answered yes, please provide additional information below

CERTIFICATION

I CERTIFY THAT THE STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ARE MADE IN GOOD FAITH. I UNDERSTAND THAT IF I KNOWINGLY MAKE ANY MISSTATEMENTS OF FACT, I AM SUBJECT TO DISQUALIFICATION AND DISMISSAL AND TO SUCH OTHER PENALTIES AS MAY BE PRESCRIBED BY LAW OR EMPLOYMENT AGENCY POLICY AND PROCEDURE.

* Signature (type name)

* Date

NOTICE TO APPLICANT CONCERNING ERASED CRIMINAL RECORDS

Under Connecticut law (1) You need not disclose the existence of any arrest, criminal charge or conviction that has been erased; (2) records subject to erasure for these purposes are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty, and a conviction for which a person received an absolute pardon; and (3) any person whose criminal records have been so erased shall be deemed never to have been arrested with respect to the erased records and may so swear under oath.

Companions & Homemakers, Inc. is an equal opportunity employer committed to hiring a diverse workforce.

Contact Information
* First Name:
* Last Name:
City:
State:
Primary Phone:
* Email:
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