Job Application

Full Name: *

Home Address: *

City / State / Zip Code: *

Number of Years at This Address:

Mobile Phone: *

Email Address: *

Social Security Number:

Date of Birth: *

Driver’s License Number: *

Driver's License State: *

Who should be contacted if you are involved in an emergency? Please, provide an emergency contact:

Relationship to you:

Emergency Contact Mobile Phone:

Emergency Contact Alternate Phone:

Job Position Applied For:

Full-time / Part time (Please choose one) *

Full Time
Part TIme

Shift(s) Desired: Days / Nights / Weekends (Please check all that apply) *

Day Time
Night Time
Weekends

When are you available to start?: *

Salary Desired:

Please, provide how much are you expected to earn per hour.

Last Employment Initial Salary:

Last Employment Ending Salary:

Who referred you to our company?:

Do you have any friends or relatives who work for Federal Caregivers Home Care, LLC? If yes, please list them here:

If hired, are you able to submit proof that you are legally eligible for employment in the United States?: *

On a scale from 1 to 10, please rate your English language level: *

What other languages do you speak?:

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?: *

What reasonable accommodation(s), if any, would you request?:

Have you been convicted of a felony or misdemeanor?: *

If you answered yes, please provide details of your conviction:

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT, UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

1 - Applicant Employment History - Employer Name:

Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent. Additionally, please list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

Supervisor’s Name:

Contact Number:

Job Duties:

Reason for Leaving:

Dates of Employment:

2 - Employer Name:

Supervisor’s Name:

Contact Number:

Job Duties:

Reason for Leaving:

Dates of Employment:

3 - Employer Name:

Supervisor’s Name:

Contact Number:

Job Duties:

Reason for Leaving

Dates of Employment:

Education History - College / University Name and Address:

Did you receive a degree?:

If yes, degree(s) received:

Education History - High School / GED Name and Address:

Did you receive a diploma?:

Other Training (graduate, technical, vocational):

Please indicate any current professional licenses or certifications that you hold:

Do you have any of the certificates listed below?

HHA/PCA Certificate (home health aide/personal care assistant)
TB Test (tuberculosis test, unexpired)
CPR Certificate (cardiopulmonary resuscitation training)

Other certifications:

1 - Reference - Name:

List any two non-relatives who would be willing to provide a reference for you:

Telephone:

Relationship:

2 - Reference - Name:

List any two non-relatives who would be willing to provide a reference for you:

Telephone:

Relationship:

Are you interested in participating in our employee benefits?:

Employment Guidelines Agreement - Type your initials in the box if you fully understand and agree with the statement below.. *

In order to take care of all our clients, we have the right to terminate a caregiver who has missed 3 or more days of work within a year without giving proper notice. Calling out of work 24 hours before a shift is not acceptable (family/personal emergencies are an exemption). Every caregiver must give at least a one week notice to request time off.

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

Certification - Please, enter your full name below if you agree to the company's terms and guidelines.

I certify that the information provided on this application is truthful and accurate.

I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Federal Caregivers Home Care, LLC to contact my former employers and educational organizations regarding my employment and education.

I authorize my former employers and educations organizations to communicate information fully and freely regarding my previous employment, attendance, and grades.

I authorize those persons designated as references to communicate information fully and freely regarding my previous employment and education.

If an employment relationship is established, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its caregiver, the employment relationship will be “at-will.”

In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause.

With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice.

Similarly, my employer will have the same right. Moreover, no agent, representative, or employee of Federal Caregiver Home Care, LLC, except in a specific written contract of employment signed on behalf of the organization by its Caregiver, has the power to alter or vary the voluntary nature of the employment relationship.

We participate with E-Verify.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Date of this job application: