Career application form

Last Page

General Contact Info

First Name *

Middle Name

Last Name *

Date Of Birth *

Ss# *

Gender *

Male

Female

Other

Address *

Apt#

City *

State *

ZiP *

Email *

Cell Phone *

Are You Eligible To Work In The USA? *

Yes

Are you legal US Citizen? *

Yes

Transportation

Some Caregiving positions require a valid driver’s or a car, including valid insurance coverage.

Do You have a Car? *

Yes

Do You have a Valid Driver’s License? *

Yes

State

Make & Model

Choose your file

Maximum file size: 2 GB

License

Education

High School *

City/State *

Degree *

Year *

College

City/State

Degree

Year

University

City/State

Degree

Year

Other

City/State

Degree

Year

Degree/Certification You Hold

Criminal History

Have You Ever Been Convicted Any Feloney or Misdesmeanor? *

Yes

If Yes Explain *

Employment History

List below last three employers, starting from the most recent/current one first.

Current Employer? *

Yes

May We Contact Your Current Employer?

Yes

Company *

Hired Date

Left Date

Job Title *

Reason For Leaving

Supervisor *

Phone Number

Duties *

References

List at Least 2 references “Family not included”.

Refrences Name *

Title *

Organization *

Email *

Phone *

Relationship *

Emergency Contact Info

List an emergency contact

Name

Phone Number

Relationship

Address

Sign & Certify

Allevia Home Care does not discriminate in their hiring practices or in any other decision on the basis of race, color, sex, sexual orientation, citizenship, national origin, veteran status, age and/or physical or mental disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and/or discharge at any time during employment. I understand that Allevia Home Care LLC is under no obligation to consider or reconsider this application at any time, and that acceptance of this application does not constitute an offer of employment.

I authorize “Allevia” to verify any and all information contained within this application, educators, employers, references, consumer credit, private or government agencies and any other individuals who may have knowledge of me or my work experience. I authorize all persons, schools, companies & law enforcement authorities to release any information concerning my background & hereby release any said persons, schools, companies & law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I agree to cooperate with such an investigation and release all parties from any and all liability, claims or damages, directly or indirectly, resulting from furnishing such information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.

Restrictive Covenant: I agree not to do business directly with any individual or business entity that Allevia Home Care LLC. has introduced to me or by entering into employment with such individuals or businesses.

Applicant Name *

Applicant Date *

General Contact Info

Transportation

Positions and Availability

Skills

Education

Criminal History

Employment History

References

Emergency Contact Info

Sign & Certify

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