Career

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

Please read "Applicant Note” below.
Complete all pages of this application.
Print clearly. Incomplete or illegible applications may not be accepted.
If more space is needed to complete any question, use comments section on the back.
Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Care Agency. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, we will terminate employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to or during employment.

Positions(s) Applied For:

Name:

Current Address:

Previous Address:

Home Phone:

Work Phone:

Cell Phone:

Email:

Valid Driver’s License #:

State Issued:

Exp. Date:

Make & Model of Vehicle:

Year of Vehicle:

Auto Insurance Co:

Policy #

Exp Date:

Have you ever applied here before? Yes / No If yes, when?

Have you ever been employed here before? Yes / No If yes, when?

How did you hear about Unique Home Care Services, Inc?

Have you have been given a copy of the job description for the position for which you have applied to review.

Yes No

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

Yes No

Why are you interested in employment with us?

What date are you available to begin work?

Are you willing to provide service to a consumer with a pet? Yes / No

Cats Dogs Other

Are you willing to provide service to a consumer who smokes?

Yes No

Describe any training or life skills you have that apply to caring for seniors or persons with disabilities:

Describe any work history you have that would apply to caring for seniors or persons with disabilities:

What do you like (or think you would like) most about working with older adults or persons with disabilities?

What do you like (or think you would like) least about working with older adults or persons with disabilities?

What personal rewards do you get from working with seniors or persons with disabilities?

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER

Are you currently working for this employer?

Yes No

If yes, may we contact?

Yes No

Company Name

City

State

Phone Number

Dates Employed: From

Job Title

Supervisor's Name

Duties

Salary $

Per(Hour, Week, Month)

Reason for Leaving

SECOND MOST RECENT EMPLOYER

Company Name

City

State

Phone Number

Dates Employed: From

Job Title

Supervisor's Name

Duties

Salary $

Per(Hour, Week, Month)

Reason for Leaving

THIRD MOST RECENT EMPLOYER

Company Name

City

State

Phone Number

Dates Employed: From

Job Title

Supervisor's Name

Duties

Salary $

Per(Hour, Week, Month)

Reason for Leaving

SECURITY

*******Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.

List states and countries of residence for the past seven years:

Have you had any moving traffic violations?

Yes No

If yes, please describe:

Have you been charged/convicted of a felony and/or misdemeanor/or served time

Yes No

If yes, please describe:

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

Yes No

CERTIFICATION AND RELEASE :

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Unique Home Care Services, INC and myself is terminable at-will so that both the company and I remain free to choose to end our work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.