Employment Application

Life @ Home, LLC Employment Application

Most feilds are required. Incomplete applications will delay interview/hire.

Today's Date
Date Available for work
Expexted hourly pay
First Name
Middle Name
Last Name
Email Address
Cell Phone Number xxx-xxx-xxxx
Home Phone Number xxx-xxx-xxxx
Address
City, State
Zip Code
Date of Birth xx-xx-xxxx
Driver License Number
Driver License State
Social Security Number xxx-xx-xxxx
Have you ever worked with this the agency before? If yes explain why you left.
Have you ever been convicted of a crime? If yes explain.
Do you have any condition that will prevent standing for long periods, kneeling, stooping, bending, or lifting? i.e. Knee, back, neck, wrist injury. If yes, explain.
Do you have High School Diploma	Yes No
GED	Yes No
Current Driver License	Yes No
Current Auto Insurance	Yes No
Do you have your own vehicle to get to/from work and take clients to appointments/shopping?	Yes No
Are you interested in	Full Time Part Time PRN
Would you consideer	Live In Overnight Back-up staffing
Have you worked with the elederly and/or disabled before?	Yes No
Please check all that you have experience with:	Muscular Dystrophy Multiple Sclerosis Quadriplegia Papraplegia Traumatic Brain Injury Seizures Behavior Management Diabetes Hypertension Down Syndrome Arthritis CVA Autism Males Females Adults Children
Proffesional certifications or special qualifications: CNA, CMA, CPI, CPR, First Aid, ...

Reference one Name
Phone
How you know them co-worker, supervisor, ...
Reference two Name
Phone
How you know them co-worker, supervisor, ...
Reference three Name
Phone
How you know them co-worker, supervisor, ...

I hereby authorize Life@Home, LLC to conduct a background check on me.	Yes No
Current Address
City, State, Zip
Previous address
Previous City, State, Zip

Press "submit" one time and wait for acknowledgement page. Thank you.