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Home
About
Services
Personal Care Services
Home Health Aide Services
Homemaking Services
Companion Care Services
Alzheimer’s & Dementia Care
Live-In & 24-Hour Care
Respite Care
Pediatric Home Care
Private Duty Home Care
Veterans Care Services
Training
Blog
Service Areas
Careers
Contact
Schedule Consultation
Home
About
Services
Personal Care Services
Home Health Aide Services
Homemaking Services
Companion Care Services
Alzheimer’s & Dementia Care
Live-In & 24-Hour Care
Respite Care
Pediatric Home Care
Private Duty Home Care
Veterans Care Services
Training
Blog
Service Areas
Careers
Contact
Home
About
Services
Personal Care Services
Home Health Aide Services
Homemaking Services
Companion Care Services
Alzheimer’s & Dementia Care
Live-In & 24-Hour Care
Respite Care
Pediatric Home Care
Private Duty Home Care
Veterans Care Services
Training
Blog
Service Areas
Careers
Contact
Schedule A Consultation
application form
Step
1
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3
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Company Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Please Answer All Questions. Résumés Are Not A Substitute For A Completed Application.
We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed servicemember status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state, or local laws. For American best care Employers Only: This Company is subject to the Workers' Compensation laws of the State of Rhode Island.* THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.
Applicant Name
(Required)
Position Applied For (list only one)
Telephone Number
(Required)
Alternate or Cellular Telephone Number
Present Address
(Required)
Present Address
City
State
Zip
How long have you lived in PA
Months
Email Address
(Required)
If under the age of 18, can you produce the necessary work certificate at the time of employment?
Yes
No
Type of employment desired
Full-time
Part-time
Specify Hours
Are you willing towork overtime?
Yes
No
Date on which you can start work if hired
MM slash DD slash YYYY
Have you previously applied for employment with this Company?
Yes
No
Have you ever been employed by this Company?
Yes
No
If applicable, below list any other names by which you have been known which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname, etc.
Applicant Certification
Education
High School
Address
Street Address
City
State / Province / Region
Course of Study or Major
Graduate?
Yes
No
Number of Years Completed
Honors Received
College
Address
Street Address
City
State / Province / Region
Course of Study or Major
Graduate?
Yes
No
Number of Years Completed
Honors Received
Graduate or Professional
Address
Street Address
City
State / Province / Region
Course of Study or Major
Graduate?
Yes
No
Number of Years Completed
Honors Received
Trade or Correspondence
Address
Street Address
City
State / Province / Region
Course of Study or Major
Graduate?
Yes
No
Number of Years Completed
Honors Received
Applicant Certification
Work Experience
Work Experience Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first. Provide information for at least the most recent ten (10) year period. Attach additional sheets if needed. If self-employed, supply firm name andbusiness references. You may include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment. Do not answer "see résumé." Employer
Name
Address
Type of Business
Telephone
Dates Employed
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Job Title
Duties
Supervisor's Name
May we contact?
Yes
No
Reason for Leaving
What will this employer say was the reason your employment terminated?
Were you ever disciplined?
Yes
No
How much notice did you give when resigning? If none, explain.
Employer
Name
Address
Type of Business
Phone
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Name
Position
Company
Work Relationship
Telephone
Please list the names of personal references (not previous employers or relatives) who you know that we may contact.
Name
Address
Type of Business
Telephone
Dates Employed
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Occupation
Address
Job Title
Duties
Supervisor's Name
May we contact?
Yes
No
Reason for Leaving
What will this employer say was the reason your employment terminated?
Were you ever disciplined?
Yes
No
How much notice did you give when resigning? If none, explain.
Have you ever been terminated or asked to resign from any job?
Yes
No
Has your employment ever been terminated by mutual agreement?
Yes
No
Have you ever been given the choice to resign rather than be terminated?
Yes
No
Applicant Certification
REFERENCES
Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.
Name
Position
Company
Work Relationship
Telephone
Name
Position
Company
Work Relationship
Telephone
Please list the names of personal references (not previous employers or relatives) who you know that we may contact.
Name
Occupation
Address
Telephone
Number of years known
Name
Occupation
Address
Telephone
Number of years known
Applicant Certification
DRIVING INFORMATION [Optional](Complete only if driving is an essential function of the job for which you are applying).
Do you have a current valid driver’s license?
Yes
No
If you do not have a driver’s license for the state in which you currently reside, why not?
Has your license ever been suspended or revoked?
Yes
No
Do you have personal automobile insurance?
Yes
No
Have you ever been denied personal automobile insurance or has it ever been terminated or suspended?
Yes
No
Please list all moving traffic violations in the last five (5) years
Offense
Date
MM slash DD slash YYYY
Location
Comments
Offense
Enter Offense here
Date
MM slash DD slash YYYY
Location
Comments
Applicant Certification
APPLICANT CERTIFICATION
Consent
I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver's license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.
Consent
I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company's policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company's policies and applicable federal, state, and local law.
Consent
I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement.
Consent
I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.
THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOTMODIFY ITS POLICY OF EMPLOYMENT AT-WILL.
I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state and/or local law. If applicable and allowed by law, I will receive separate written notification regarding the Company's intent to obtain "consumer reports."
I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, I authorize the company to provide truthful information concerning my employment to future employers and hold the company harmless for providing such information.
If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States.
THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.
Signature
Date
MM slash DD slash YYYY
If the applicant is a minor, the foregoing release and consent must be signed by the applicant's parent or legal guardian. Signature by the applicant's parent or legal guardian constitutesacknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant's legal guardian.
Parent or Legal Guardian
Date
MM slash DD slash YYYY
Witness
Date
MM slash DD slash YYYY
Witness
Date
MM slash DD slash YYYY
IT IS UNLAWFUL IN MASSACHUSETTSTO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.
FOR CALIFORNIA APPLICANTS ONLY:
BY CHECKING THIS BOX, I WAIVE MY RIGHT TO RECEIVE A COPY OF ANY PUBLIC RECORD OBTAINED BY THE COMPANY FOR EMPLOYMENT PURPOSES THROUGH AN INTERNAL INVESTIGATION.
FEDERAL AND/OR STATE LAW MAY PROHIBIT THE USE OF LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS WELL. THIS APPLICATION MAY NOT BE SUFFICIENT FOR ALL INDUSTRIES OR APPROPRIATE FOR USE IN ALL LOCALITIES. *This employment application not appropriate for use by American best Care employers exempt from the state’s Workers’ Compensation laws.
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