At Home and At Play
Employment Application
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  • Contact Information

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  • Length at Address

  • Emergency Contact Information

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  • Position Information

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  • Consent for Criminal Record Check

    I, the undersigned, grant my consent to At Home Health Care Agency to request that a criminal background check be performed through the Indiana Department of State Police for data related to any criminal conviction obtained against me. I, the undersigned, understand that a conviction for or being presently charged with any crimes may prevent me for being eligible
    For employment with At Home Health Care Agency.
  • General Information

    A description of the section goes here.
  • If Yes Please give date of application:
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  • If Yes Please give date of Employment:
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  • If yes, in the box below please explain the number of convictions, nature of each offense(s) leading to conviction(s), date(s) of the offense(s), sentence(s) imposed, and type(s) of rehabilitation.
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    If Yes to previous question
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  • References

    Provide information requested below for 3 references who are not related to you. Professional references are preferred; academic references are permitted.
  • Reference 1

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  • Reference 2

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  • Reference 3

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  • License(s)

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  • Education History

  • High School/Other
  • College/Other
  • Work History

    List your work experience starting with your most recent job.
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  • Attachments

    If you would like to attach your resume or any certification documents you have please attach below.
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  • Applicant Attestation

    By signing this document I attest that the education history, job history, and other information included in this application is true and accurate
  • Please type your full name in this field.

  • At Home Health Care, LLC, does not discriminate against any person on the basis of race, color, national orgin, disability, or age in admission, treatment, or publication in its programs, services, and activities or in employment. For further information about this policy contact Lititia Hatcher-Roque, 260-755-2727.