ࡱ> 7 <bjbjUU 47|7|t6}l"""68467>  !###y7{7{7{7{7{7{7$89 X;7"#r#@###7' !h7'''#jl " !y7'#y7''03,"]3 ! rFX6J$)3]370713,X<$X<]3'66EMPLOYMENT APPLICATION 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 pf 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 Instead Senior Care franchise. 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, terminating 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 employment.  PERSONAL INFORMATION Todays Date: _____________________________________ Positions(s) Applied For: ____________________________________________________ Name: _______________________________ _________________________________ _____________________ Last First Middle Current Address: _________________________________ _______________________ ______ ____________ Street City State Zip Code Previous Address: _______________________ ______ __________________________ _____ ____________ Street City State Zip Code Home Phone: (______) ______________________ Work Phone: (______) _________________________ Cell Phone: (______) ________________________ Alternate Phone: (______) ______________________ Emergency Contact(s): ____________________________________ (______) ____________________ Name Phone ____________________________________ (______) ____________________ Name Phone Valid Drivers License #: __________________________ State Issued:_____________ Exp. Date:__________________ Make & Model of Vehicle:____________________________________________ Year of vehicle:___________________ Auto In Co:__________________________ Policy #_______________________ Exp Date:_____________________ Have you ever submitted an application here before? Yes / No If yes, when? ___________________________________ Have you ever been employed here before? Yes / No If yes, when? __________________________________________ How did you hear about our Home Instead Senior Care franchise? ___________________________________________ 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? __________________________________________________________ _________________________________________________________________________________________________ AVAILABILITY Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked. What date are you available to begin work? ___________________________ Please complete all areas of availability: ______Mornings ______Afternoon _______Evenings _______Overnights ______Weekdays _______Weekends Please indicate the days of the week as well as the earliest and latest times that you are available for work. MondayTuesdayWednesdayThursday FridaySaturdaySundayShiftFrom:To: PREFERENCES Please indicate all areas of the city in which you are willing to work: ___Bucks County ____Northeast Philadelphia _____Eastern Montgomery County Please indicate the types of services which you are willing to provide: CompanionshipHousekeeping (dust/vacuum)Errands/Shopping/Transportation*Meal PreparationLaundry/IroningPersonal CareActivities (games/crafts)Medication RemindersDementia/Alzheimers Care*In order to be able to provide transportation or run errands, you will be required to have a valid drivers license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required. Are you willing to provide service to a client with a pet? Yes / No If yes, which ones: ______Cats ______Dogs Are you willing to provide service to a client that smokes? Yes / No JOB RELATED SKILLS Describe any training or life skills you have that apply to caring for a senior: ____________________________________________________________________________________________________________________________________ Describe any work history you have that would apply to caring for a senior: ____________________________________ ________________________________________________________________________________________________ What do you like (or think you would like) most about working with older adults? ________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ What do you like (or think you would like) least about working with older adults? ________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ What personal rewards do you get from working with seniors?_______________________________________________ __________________________________________________________________________ EDUCATION * Please circle highest grade completed: Grade School: 6 7 8 High School: 9 10 11 12 College: 13 14 15 16 16+ School TypeSchool NameCity, StateMajor/Subject# Yrs AttendedGraduateHigh SchoolY / NVocational/TechnicalY / NCollege/UniversityY / N*For employment our minimum education requirement is either a GED or High School diploma 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 ___________ to ___________ ______________________________ _____________________________________ Job Title Supervisor's Name ______________________________________________________________________________________________________________________ Duties $______________ per __________________ ____________________________________________________________________________ Salary (Hour, Week, Month) Reason for Leaving SECOND MOST RECENT EMPLOYER _______________________________________ ________________________ _______ ( _____ )______________________________ Company Name City State Phone Number Dates Employed: From ___________ to ___________ ______________________________ _____________________________________ Job Title Supervisor's Name ______________________________________________________________________________________________________________________ Duties $______________ per __________________ ____________________________________________________________________________ Salary (Hour, Week, Month) Reason for Leaving THIRD MOST RECENT EMPLOYER _______________________________________ ________________________ _______ ( _____ )_____________________________ Company Name City State Phone Number Dates Employed: From ___________ to ___________ ______________________________ _____________________________________ Job Title Supervisor's Name ______________________________________________________________________________________________________________________ Duties $______________ per __________________ ____________________________________________________________________________ Salary (Hour, Week, Month) Reason for Leaving SECURITY *******Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check. As a condition of employment all employees must be Bondable& Insurable. Are you at least 19 years of age? Yes / No List states and counties 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: Incident City/State Charge 1) _____________________________________________________________________________________________ 2) _____________________________________________________________________________________________ Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? Yes or No. REFERENCES (Do not include relatives) Please complete all six references. Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 6 references, you will be asked to provide additional references. Full NamePhone NumberBest Time of Day to CallRelationshipNumber of Years Known1)H ( ) W ( )AM / PM AM / PM2)H ( ) W ( )AM / PM AM / PM3)H ( ) W ( )AM / PM AM / PM4)H ( ) W ( )AM / PM AM / PM5)H ( ) W ( )AM / PM AM / PM6)H ( ) W ( )AM / PM AM / PM 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 Interim Management Inc, and myself is terminable at-will, so that both the company and I remain free to choose to end out 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. ____________________________________________________________ _______________________ APPLICANT SIGNATURE DATE     PAGE  ( I.M.A., Inc., T/A Home Instead Senior Care an independently owned and operated Home Instead Senior Care franchise. ( I.M.A., Inc., T/A Home Instead Senior Care an independently owned and operated Home Instead Senior Care franchise.  INCLUDEPICTURE "https://franchisecenter.homeinstead.com/Logos/HISC_LOGO_Black_Horz_preview.jpg" \* MERGEFORMATINET  (<=gh  3Ci j k l m n @ Z    b4ҽҽҽҽҽұxnnnnnnbnCJ OJQJ^JaJ hCJOJQJ^Jh5>*CJOJQJ^JaJh5>*CJ OJQJ^JaJ hCJ OJQJ^Jh jOJQJU^JmHnHu5CJ OJQJ^Jh jOJQJ^Jh5OJQJ^JhOJQJ^Jh *5CJOJQJ^JaJh5CJOJQJ^JhjUmHnHu&;f 34i j l m   n $1$a$-$d %d &d 'd -D1$M N O P Q 1$$1$a$t:;<n @ Z   b c b45uvS 1$^` -D1$M 1$^`1$45uv/7DE#$kl}PR묞CJOJQJ^JaJh5>*CJ OJQJ^JaJ h5CJOJQJ^JaJhCJOJQJ^JaJh5>*CJOJQJ^JaJhCJOJQJ^JaJh5CJ OJQJ^JaJ h5OJQJ^JhOJQJ^JhCJ OJQJ^JaJ h.ST8DE#$kl}~ *$1$If$1$If1$P4FfFf$1$If $$1$Ifa$0$1$If1$Ff 01A;3333$1$If$$Iflֈ {*   t0644 lalABPQRl34$$Iflֈ {*   t0644 lal$1$Iflm3$$Iflֈ {*   t0644 lal$1$IfABU+o1f !".Udh-D1$M dh1$1$ABTU-. !!N$j$k$'õީ|ސrfYީ||rSr >*CJaJ56>*OJQJ^Jh>*CJOJQJ^JhCJOJQJ^Jh5OJQJ^Jh>*OJQJ^Jh5>*CJOJQJ^JhCJOJQJ^JaJhCJOJQJ^JaJh>*CJOJQJ^JaJh5>*CJOJQJ^JaJhCJ OJQJ^JaJ hOJQJ^JhCJ OJQJ^JaJ h6CJOJQJ^JaJh U $$1$Ifa$dh-D1$M    <\4444$1$If$$Iflhֈ,R&*pJ t0644 la+)$$Iflhֈ,R&*pJ t0644 la $$1$Ifa$$1$If+,-./5 $$1$Ifa$$1$If56IJKL*CJKH\aJh5OJQJ^JhOJQJ^Jh6OJQJ]^JaJhOJQJ^JaJh5B*OJQJ^JphB*OJQJ^JphB*CJ OJQJ^JaJ phCJOJQJ^Jh5>*CJOJQJ^Jh5>*CJOJQJ^JhCJOJQJ^Jh >*CJaJ+ ,,,,-}--9../u/v//000001 $$1$Ifa$1$dh-D1$M $-D1$M a$dh1$ -D1$M -DM //// 00 181:1>1k1m1q111111122 27292:2;2U2W2 7K8a899T:t:u:w:x:z:{:}:~:::::::̴̴̴̴̴̴¦̇{x{x0J j0JU jUCJaJCJh 0JCJ] 0J6CJCJhh5h5CJOJQJ^JaJh5CJOJQJ^JaJh5OJQJ^JhOJQJ^Jh>*OJQJ^Jh>*CJOJQJ^JhCJOJQJ^Jh5CJOJQJ^Jh/11 11(10181LDDD99 $$1$Ifa$$1$If$$IflrF$*~ TT t0*62 44 la8191:1;1>1M1[1B$$Ifl$rF$*~ TT t0*62 44 la$1$If[1c1k1l1m1n1.$$IfllrF$*~ TT t0*62 44 la$1$If $$1$Ifa$ $$Ifa$n1q1111111 $$1$Ifa$ $$Ifa$$1$If111111JBBB9 $$Ifa$$1$If$$Ifl?rF$*~ TT t0*62 44 la11111117$$IfllrF$*~ TT t0*62 44 la$1$If $$1$Ifa$111222 $$1$Ifa$ $$Ifa$$1$If22 22'2/2JBBB9 $$Ifa$$1$If$$Ifl?rF$*~ TT t0*62 44 la/2728292:2;2741$$$IfllrF$*~ TT t0*62 44 la$1$If $$1$Ifa$;29T:t:v:w:y:z:|:}:::::::;;;;|;};;;;h]h$a$&`#$xxxx1$$1$a$:::;;;;|;};;;;;;;<<<<<<CJaJ jU jUo(B*CJOJQJ^JaJphCJOJQJ^J jCJOJQJ^JCJOJQJ^JaJ;;;;<<<<xx2 00&P1h/ =!"#$%@`$$Ifl vT :HzT!0&*F2 t0<+6$$$$44 la$$Ifly vT :HzT!0&*F2 t0<+6$$$$44 la$$Ifl vT :HzT!0&*F2 t0<+6$$$$44 la$&Dd  S A:,HISC_LOGO_Black_Horz_previewBlack Horizontal LogoR(%f :5hvXmfT%%F$f :5hvXmfTJFIFHHC  !"$"$C}" N!"1AQU#2a 7qu8Br$346RSstv%9Cbc ?z4h4h4h4h4h4hNCҩf\l%IJTꬌc>EŬljMP~;I܌IZQABNݠ{}V궷Reuܧnza8F|: jtTiI]#d6 Sn`(kR(% D:Υ^%BWd /0!YJpkuZpAZ4h4h4h4h4h4h4hfћٻ{5U36fUU)ZQ-敶^WN0Zof*exv3X-ˍ  q)Z [gꐞ.s1?QvW7d?ˏqJwZ-[uShqiwٯx7[yl5&m!]Zx=I8?P+Hѵ?{5fDW5n4nGms6W+#]h5~)BӪv<j  T4\S.:,(][@'eD x ܷګU%.lΘJɆemaHR}CWuVK\Y8ѧǞP?᠚ѯ('٪KəV"%oHTSp HՈVSԔ¦vdPmpMU\KjROJf͸JJq*d BQcD*4Iدۈ(P:ݹ[GhTqᘈYDr'^Az^{L۽VC̪Msa Hdd0:ѹ}(֬fnELRC*M29A ^1Gcj] \Q>Rry^ײ|Y-!$rX m9 )y۝PrݦW4eO|P9{,CQnf ۊB`kqϹw"?f-gߔù }Zvhi㠅RY*@R`}M95B3 q C:s+Ril?ԯA ͢Wr6SvZmDPe*WvBR+ @o;?\[Rgn(AeEZItX*ٝW߸Nv݁]8!ѫm*KwDiO@R|IBAIP Dv#{j^w Ѧz+omIq SeJWUy'>P;Zk4 b^0i%1³ԥ!JHS ؃\3Om|[^j,6LKA!a@4Uݤ$+݈?5?KZuo4]FٻZ5&1,fSC6m! g*QddX}%Q $2g,kRO5*{/pZCm`-kw*ޢv܁ӛSzWGm0QV6NxNU3j(1#Qk)P+-Nc *<꿹I{NXmR)u2S IK[JC NS9!\Jp@$i1U-=m54-nCm$8k=[B:QX퉸vVܤΤCr_ B8 )@:i7}O_d4;m.;| Sql$-W8<֣ـ^=YX֑ݿ`]U&="~2oF*W)qG }Ogkk^^b1v>֕Ҋ,i*q+X?k͚rѢnU9weVʝ gIH$uƳfUR_65GRַR?i N-ٽau2/-d Zݜ ,OL'n߶M {TeX@B䰳~0CpSPnsYR63u(E-8Cuh[AȽbvhTI%G=t7[6?`v";P}**>Ѝ"||*"$;FlӼ" *GtS.,03g|&'] MOmnnFh׍w M[%¸)ºRif4S,ӤHBJoN:Uznmh?$n]V-ܷ!)KW7_q]VRz?%2;MY-!E+>dl%<߇}t7[6?znmh]ي۫] ˧9Q(qS.WA@<@}݋BP(ج2S, r|F=NGk1znmho?$k/ nش\h!OZ4)ʉCǘ#æ=J{[/s*Dr[Q\ 9RH883}t7[6?znmh4[c7-fؽ`\WOQtL-œC ]ԝk'TV6nZRM0#)Ryeg\(drx2%LgW6' # ]A*ٸa U5B(iԬ@'.mzNo^G–;[kp$#H‡ nЈa=1iw>#'$ddFT˦=J$uc$^ß4+xn䷣?1mz+/4NJI=>XAY҆&dOBݷ§§3Q"5ZI=O2t&1N)u ]qcO;݀U+2p=v{syAe8R:{"y-_Lw*!% ˮ%9whVnۭKv.~AP}msOXJ=FmM}Q1Hm()*vm\m5bЮڦџq 2Ck:b9 jRI=@HY`26OCm>L ŵwhY;W EU;RTVmƒCRBd*0Jdw VgŢN_&$hqD(pT`87F Vvo4d*bif0ZIVR ct.(Rn*6y/!ogaC!HI)ITZ^\[U|B[pHn]<%R`HXB O&$rΩWE6ƧW7MZ9Kt#J]RHN:˦U!PD3\mSRx#JW^s.ԠJ R}6oNM }9Po)gBfwЧMRܪ7ͦr+T:Ogn%jDC~t6Um%#y j) ΩϷJʧ&.ķ˵ʥc.!YxORQ5D]JR6%G'ߌkV\Ι&YaWmk0e {JRBC$ws$r'#YZkuhH"W!۪o>@V<$g@?$дsGؒ}2:cP"\VjI碷Ivq<~\;2_t=ݸ7e`Ǝ aTRF:Y,/Zn(Cq:Bp1ѿ[w3aڃM@Sʃ,UW:=Koͱuh3Ovb>Rl}im ]~mԻj1vGZ[F4m_.ߛc.ڿ]6֖Ѡ>W:=Koͱuh3Ovb>Rl}im ]~mԻj1vGZ[F4m_.ߛc.ڿ]6֖Ѡ>W:=Koͱuh3Ovb>Rl}im ]~mԻj1vGZ[FW[hm%RPVdPe,'<rx=stѣ@hѣA tLwKRhH]B>8!䒜cX{ޱeTiU 4_S1\$8"-F9^;lǾڪ;5B&PРAMTF%϶hl3LZXC1.aNprz$iԥ.iJ} _֪kqV. }M5\H]Iz?%Q[kR<|# տbԨ=vϰn>ԯ߳\뢨^uqA8h+’@+898h% ѷy[~AfBVr')NS&^soEP#SDgRq)k#8Y A8 Npph7sgmEP锺OBSy +q\Š[BA' R@Ii#L4, H[8>4$u=pOFxlKBeW+Sl#9;)tmZ=IUpoEH:Ei6>er4%-<灘.AKd9i]J|hp75aV&$i!ȕBF] QG𶔕+-xӕgm5&踨 qTMDeNZ҄ek*OCFuЩPWgB 6N:`E)(R0\PX5cn(4yՋ% 4s%JPq[Hy!iѥm7-UT[UɊN6iDqqKJ +K #Ō`sKNU햡9&)6.)ꂲBi;Ũ+$@14j7ڑpơOARڽ).䜂A)8'Qs=s)ϴ KVBU`25uȵ\5ezK8C-#KQHk7 +!+RC.(@'5B^^rmV!hpa2RIh>j$)-dA!;b7q yPv <ysqY%#ѣ@hѣ@kѝ`厙\g]4hfnUe=B *.\*R:L8J B)N etZQwZv*=j<8듥PXiD~V:T #N=HBǥ,nVRzjR(%Dt~ƾgn2 SsJi씃#`dʸi$Wk6Σ\u2ߗ+R0Jc#R^D$jvƳkܷ/;Qi2eCC> JGHN4Ѡ5;TZƧћx/u* ^x $d&Vt\vT4ZENE29Ȑ@ 9ڊAO^3h[anJ*P*QQVR 8Rb6TqUd8H!NI6R6U%+q# (,jͣABnU-٢\uHMڗ8\+)[ <9UFe6F$J+Vŧ-4 {φcM N&бݧ X-M-[-c-k-l-m-n-q--------------------.... ..'./.7.8.9.:.;.5T6t6v6y6|6666667777|7}777777788800000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000(0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 00000 4'/:< $,57Bn SAlU+5L^&+181[1n11112/2;2;<!#%&'()*+-./01234689:;<=>?@AC<" !wyCt    /XR$ӝ5G]JR$qI RA@f  (  bB  c $Dp"?b   3 #" `? B S  ?H0(  j8  >{*at{*tt6t6v6v6w6w6y6z6|6}666778v x     cg2 2t6t6v6v6w6w6y6z6|6}666778333333333@@       S T 0TU"+-..T^`ce'''''' ( ( ((((})})))))))9*9*+v+222 3M33K4m45555s6t6t6v6v6w6w6y6z6|6}66666677777777}77777788 Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blacker]C:\Documents and Settings\Joanne Mullin\Desktop\CAREGiver_Employment_Application(NEW ONE).doc Larry blackerC:\Documents and Settings\Joanne Mullin\Application Data\Microsoft\Word\AutoRecovery save of CAREGiver_Employment_Application(NEW ONE).asdYEt.̢3^`o() ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.YEt.         }~01ABPQRlmU   +,-./56IJKLMST+,,,,,-- -(-8-9-:-;->-[-k-l-m-n-q--------------.... .'.7.8.9.:.s68@C8P@UnknownGz Times New Roman5Symbol3& z Arial?Wingdings 2G MS Mincho-3 fg"1hA,_-a!0d#75 2QX Caregiver Employment Application1caregiver, employment application, human resource Larry blacker Larry blackerOh+'0,8H `l    !Caregiver Employment ApplicationrosareLarry blackeroy2caregiver, employment application, human resourcetareNormaleLarry blackerlo19rMicrosoft Word 9.0n@@X@#@:X,Item Propertiesns:ds="http://schemas.openxmlformats.org/officeDocument/2006/customXml"/>"" ma:contentTypeName="Document" ma:contentTypeID="0x01 //schemas.microsoft.com/office/2006/metadata/contentType" xmlns:ma="http://schemas.microsoft.com/office/2006/metadata/properties/metaAttributes"> ?@ABCDFGHIJKLMNOPQRSTUVWXYZ[]^_`abcdefghijklmnopqrstuvwxyz|}~Root Entry FaEData E,1Table\X<WordDocument4SummaryInformation({DocumentSummaryInformation8TCompObjjObjectPoolpFXpFX   FMicrosoft Word Document MSWordDocWord.Document.89qDocumentLibraryFormDocumentLibraryFormDocumentLibraryForm This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. w>