EmailMe Form - At Home and At Play

First Name *

Last Name *

Middle Name

Maiden Name

Date of Birth *

MM / DD / YYYY

SSN

Marital Status

Single

Married

Divorced

Widowed

Contact Information

Home Phone *

### - ### - ####

Cell Phone

### - ### - ####

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Length at Address

Months

Years

Emergency Contact Information

Name *

First Last

Phone *

### - ### - ####

Relationship *

Position Information

Position(s) Applied For *

Desired Status *

Full-time: 40 Hrs/Wk

Part-Time

PRN

Desired Compensation
(Per Hour) *

$ Dollars . Cents

Desired Compensation
(Per Year)

$ Dollars . Cents

Date Available to Start *

MM / DD / YYYY

Day Available to Work *

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 you are under 18 years of age, can you provide required proof of your eligibility to work *

Yes

No

Have you ever filed an application with us before? *

Yes

No

If Yes Please give date of application:

Date of Application *

MM / DD / YYYY

Have you ever been employed with us before? *

Yes

No

If Yes Please give date of Employment:

Date of Employment

MM / DD / YYYY

Are you currently employed? *

Yes

No

Are you currently on layoff status to recall? *

Yes

No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? *

Yes

No

Have you been convicted of a crime within the past 10 yrs? *

Yes

No

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.

If you answered Yes to the previous question please tell us about your conviction(s)

Can you travel if a position requires it? *

Yes

No

Do you have a reliable means of transportation to from/work? *

Yes

No

Do you have a valid drivers license? *

Yes

No

Drivers License Number

State of Issue

Have you ever been in the armed forces? *

Yes

No

Have you ever been or are you now in the National Guard? *

Yes

No

Date Entered

MM / DD / YYYY

If Yes to previous question

Discharge Date

MM / DD / YYYY

References

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

Reference 1

Name *

First Last

Phone *

### - ### - ####

Years known *

Relationship *

Reference 2

Name *

First Last

Phone *

### - ### - ####

Years known *

Relationship *

Reference 3

Name *

First Last

Phone *

### - ### - ####

Years known *

Relationship *

License(s)

Licensed As

State of Issue

License Number

Date of Issue

MM / DD / YYYY

Date of Exp.

MM / DD / YYYY

Licensed As

State of Issue

Licensed Number

Date of Issue

MM / DD / YYYY

Date of Exp.

MM / DD / YYYY

Education History

School Name *

High School/Other

State *

Graduated *

Yes

No

Degree Awarded

School Name

College/Other

State

Graduated

Yes

No

Degree Awarded

Work History

List your work experience starting with your most recent job.

If you are currently employed may we contact your current employer? *

Yes

No

N/A

Employer *

Phone *

### - ### - ####

City *

State *

Employed From *

Employed To *

Starting Pay *

$ Dollars . Cents

Ending Pay *

$ Dollars . Cents

Reason For Leaving
(be Specific)

List duties performed, skills used or learned, and advancements of promotions: *

Employer

Phone

### - ### - ####

City

State

Employed From

Employed To

Starting Pay

$ Dollars . Cents

Ending Pay

$ Dollars . Cents

Reason For Leaving
(be Specific)

List duties performed, skills used or learned, and advancements of promotions:

Employer

Phone

### - ### - ####

City

State

Employed From

Employed To

Starting Pay

$ Dollars . Cents

Ending Pay

$ Dollars . Cents

Reason For Leaving
(be Specific)

List duties performed, skills used or learned, and advancements of promotions:

Attachments

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

Attach Resume/Document(s)

(optional)

Attach Resume/Document(s)

(optional)

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

Electronic Signature *

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.