Application Form - Wendyman Home Care LLC

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Application For Employment:
Wendyman Home Care LLC

Wendyman Home Care LLC is an equal Opportunity Employer. Employment offers are made on basis of qualifications, and without regard of race, sex, religion, national or ethnic origin, disability, age, veteran status or sexual orientations.
Please complete this employment application form for consideration. We strongly suggest proof-reading your application before clicking the submit button. We look forward to working with you!

PERSONAL INFORMATION

First Name*

Middle Name

Last Name*

Other names Used

Address*

City*

State / Province*

Postal / Zip Code*

Email Address*

Phone Number*

Are you legally entitled to work in the U.S.?*

Yes

Have you ever been convicted of a felony*

Yes

Are you 18 Years of age or older*

Yes

Are you currently employed?*

Yes

May we contact this employer?*

Yes

Company Name

Company Address

Current Job Title

Current Job Department

Have you ever been employed by Wendyman Home Care LLC?*

Yes

Date from

MM slash DD slash YYYY

Date To

MM slash DD slash YYYY

Reason for leaving

Are you related to any current Wendyman Home Care LLC Employee?*

Yes

Their name

Their relationship to you

If required for position, do you have a valid Driver License?*

Yes

State issued, License # & Expiration date

If required for position, do you have a valid Proof of insurance*

Yes

Insurance Company & ID #

How did you learn about this employment opportunity at Wendyman Home Care LLC? Check all that apply**

Job Bulletin posting / walk

Referral by employeee

Depart. Of labor

Website

Other

POSITION

Position Applying for*

CNA

HHA

CAREGIVER

Administration

Office | Clerical

Date Available*

MM slash DD slash YYYY

Applying For*

Part-Time

Full-Time

Temporary

Days

Evenings

Nights

Days Available to work*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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

Yes

Please Explain

EDUCATION AND TRAINING

School Name

City | State

Dates Attended Month/Year(From)

Dates Attended Month/Year(To)

Did you Graduate?

If no, # of years left to graduate

Degree received

Major

School Name

City | State

Dates Attended Month/Year(From)

Dates Attended Month/Year(To)

Did you Graduate?

If no, # of years left to graduate

Degree received

Major

Other credentials – Licenses | Certifications or professional affiliations, etc., which are relevant to the job(s) for which you are applying.

Type of License | certifications

License and | Certification # and State Issued

Expiration Date

Type of License | certifications

License and | Certification # and State Issued

Expiration Date

Special Skills you have to offer for this position

EMPLOYMENT HISTORY (Begin with Most Recent Employment)

Employer #1 (Company Name)*

Job Title & Duties*

From*

MM slash DD slash YYYY

To*

MM slash DD slash YYYY

Supervisor's Name*

Phone*

Address*

Reason for leaving

May We Contact This Employer?

Yes

Employer #2 (Company Name)

Job Title & Duties

From

MM slash DD slash YYYY

Supervisor's Name

Phone

Address

Reason for leaving

May We Contact This Employer?

Yes

Employer #3 (Company Name)

Job Title & Duties

From

MM slash DD slash YYYY

Supervisor's Name

Phone

Address

Reason for leaving

May We Contact This Employer?

Yes

REFERENCES: Give names of three Persons NOT related to you. Two of your References MUST be supervisory or Professional*

Name

Phone #

Address

Occupation

The information on this application is true, and accurate to the best of my knowledge.*

The information on this application is true, and accurate to the best of my knowledge.

Full Name*

Signature*

Date*

MM slash DD slash YYYY

APPLICATION DISCLAIMERS

Authorization to Release Information

I have applied for a position with Wendyman Home Care LLC. I have been requested to provide information for their use in reviewing my background and qualifications. Therefore, I hereby authorize the investigation of my past and present work character, education, military and employment qualifications.
I authorize the release of my information to Wendyman Home Care LLC whether the information is of record or not, and I do hereby release all persons, agencies, firms, companies, etc., from any damages resulting from providing such information.
This authorization is valid for 180 days from the date below. Please keep this copy of my release request in your files.

Signature

Name

Date

MM slash DD slash YYYY

Consent for Drug/ Alcohol Screen Testing

If you are offered and accept employment with Wendyman Home Care LLC, in the interest of safety for all concerned, you will be required to take a urine test for drug and / or alcohol screening.
I have been fully informed of the reason for this urine test for drug and/or alcohol screening. I fully understand what I am being tested for, the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my potential employer and become part of my record.
If this test is positive and l am not hired. I understand that I will be given the opportunity to explain the results of this test.
I hereby authorize these test results to be released to:
Wendyman Home Care LLC

Signature

Name

Date

MM slash DD slash YYYY

Wendyman Home Care LLC -IS AN EQUAL OPPORTUNITY EMPLOYER

Applicant Acknowledgement

I certify that the information in this application is accurate, current and complete. I understand that incorrect statements or omission may result in disqualification from further consideration or termination of employment.

I authorize Wendyman Home Care LLC to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision.
I authorize Wendyman Home Care LLC to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes.
I also authorize Wendyman Home Care LLC to disclose any of my performance Appraisals, disciplinary record, or skills test for the same purpose as above.
I release Wendyman Home Care LLC and any individual or entity providing information to Wendyman Home Care LLC from all liability for any damages from the disclosure of this information.

I also understand and agree that:

Passing a medical examination and / or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated. I may not be hired, or if hired, employment may be terminated.
Subject to applicable state laws, Wendyman Home Care LLC reserves the right to conduct drug screening and testing for reasonable suspicion at anytime during employment and as a pre-employment requirement. Any violation of this policy shall result in an applicant not being hired or an adverse employment action up to including immediate termination. Wendyman Home Care LLC has the right to change this policy at any time as it requires.
I understand that nothing contained in this employment application or in granting of an interview creates an employment contract between Wendyman Home Care LLC and me for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable at will”, that I will have the right to terminate my employment at any time.
I understand that should I become employed by Wendyman Home Care LLC my work assignment, schedules and / or work locations are subject to change according to the needs of the business and the clients of Wendyman Home Care LLC

Signature

Name

Date

MM slash DD slash YYYY

CAPTCHA

Application For Employment: Wendyman Home Care LLC

PERSONAL INFORMATION

POSITION

EDUCATION AND TRAINING

EMPLOYMENT HISTORY (Begin with Most Recent Employment)

APPLICATION DISCLAIMERS

Authorization to Release Information

Consent for Drug/ Alcohol Screen Testing

Wendyman Home Care LLC -IS AN EQUAL OPPORTUNITY EMPLOYER

Applicant Acknowledgement

Quick Inquiry

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Application For Employment:
Wendyman Home Care LLC