Home Companion Services

Application for Employment

General Information

Position Desired *

Date Available *

First Name *

Middle

Last Name *

Address *

ZIP Code *

State *

Home Telephone

Cell Phone

Are you at least 18 years old? * YesNo

Have you been convicted* of a felony within the last 7 years? * YesNo

Please explain.

A conviction will not necessarily disqualify an applicant from employment.

Certification

Certificate

Type HHAPCACNALPN

Certificate/License #

Issued By

Date issued

Expiration Date

Education and Training

High School

School Name, City, State

Graduated? Yes

College

School Name, City, State

Degree/Major

Graduated? Yes

Vocational Training

School Name, City, State

Degree/Major

Graduated? Yes

Other

School Name, City, State

Training Received

Graduated? Yes

Employment History

Please list most recent employer first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here.

Employer

Company Name

Company Address

Company Phone

From (Month/Year)

To (Month/Year)

Your Position

Supervisor's Name

Supervisor's Position

Starting Salary

Ending Salary

Responsibilities

Reason for Leaving

May we contact your previous supervisor for a reference? * YesNo

Knowledge, Skills, and Abilities

List skills you possess and believe are pertinent to the position you seek, such as computer skills, fluency in language, supervisory skills.

Skill

References

List persons who know your work professionally, excluding supervisors

Reference

Name

Organization/Position *

Telephone

Relationship *

No family, please.

Years Known *

(Rounded to the nearest year)

Were you employed previously by us? * YesNo

When?

Do you have any relatives that work for us? * YesNo

Please be specific.

How were you referred to us?

Are you first aid certified? * YesNo

I certify that answers given herein are true and complete to the best of my knowledge.

I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge.

I authorize investigation of all references and statements contained in the application for employment as may be necessary in arriving at an employment decision.

I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contingent upon satisfactory outcome of a medical examination and criminal background check.

I understand that my employment may be terminated at any time, without liability to me for wages and salary except as have been by me at the date of such termination.

Yes