form alleviacare Step 1 of 9 11% Last Name(Required) First Name(Required) Middle Int Date Of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Other Ss#:(Required) Address(Required) Address City State ZIP / Postal Code Email(Required) Home Phone(Required)Cell Phone(Required)Are You Eligible To Work In The USA?(Required) Yes No Are You Legal US Citizen?(Required) Yes No TransportationSome Caregiving positions require a valid driver's or a car, including valid insurance coverageDo You have a Valid Driver's License?(Required) Yes No State(Required) License(Required) Do You have a Car?(Required) Yes No Make & Model(Required) If Yes, Do You Have Valid Insurance ?(Required) Yes No Proof Of InsuranceMax. file size: 2 GB. Positions And AvailabilityI 'M Applying for a Position As: Hours You're Available 1-4 Hours 5-8 Hours 9-12 hours Schedule Desire Mon Tue Wed Thur Fri Sat Sun Time Available Morning Evening Overnight Are you Available For Emergencies?(Required) Yes No Are you Available For 24hr Live-in Position?(Required) Yes No 3 Days 4 Days 5 Days More EducationHigh School(Required) City/State(Required) Degree(Required) Year(Required) College City/State Degree Year Other City/State Degree Year Degree/Certification Skills (Languages)Check All Languages You SpeakMark English Mandrin Japanese Somali Mark French Hindi German Chinese Mark Spanish Portuguese Turkish Bengali Mark Arabic Russian Swahili Other Place a Check By The Conditions or Duties You Have Experienced In:Untitled Bathing / Showering Bed-Bath Oral Hygiene Dressing Toileting Bedpan Skin Care Shaving Untitled Ambulating Transferring Transportation Hospital Bed Shower Chair Wheel Chair Hoyer Lift Gate Lift Untitled Food Preparation Meal se Nutrition Training Eating Assistant Bed Linen Change Laundry Dusting Light House Untitled Medication Assistance Combative Bed Bound Dementia Parkin's Paralyzed Diabetes Cancer Criminal HistoryHave You Ever Been Convicted Any Feloney or Misdesmeanor?(Required) Yes No If Yes Explian or N/A(Required) Employment HistoryCompany(Required) Job Title(Required) Hired Date(Required) MM slash DD slash YYYY Left Date(Required) MM slash DD slash YYYY Address(Required) Street Address Supervisor Or Contact(Required) Phone(Required)Describe your Work Responsibility(Required) Reason For Leaving(Required) Company Job Title Hired Date MM slash DD slash YYYY Left Date MM slash DD slash YYYY Address Street Address Supervisor Or Contact PhoneDescribe your Work Responsibility Reason For Leaving Company Job Title Hired Date MM slash DD slash YYYY Left Date MM slash DD slash YYYY Address Address: Supervisor Or Contact PhoneDescribe your Work Responsibility Reason For Leaving May We Contact Your Current Employer Yes No Explain About your Current Job(Required) ReferencesList at Least 2 references "Family not included."Refrences Name(Required) Refrences Name Title Organization(Required) Email(Required) Phone(Required)Relationship(Required) Refrences Name Title Organization Email PhoneRelationship Refrences Name Title Organization Email PhoneRelationship Sign & CertifyAllevia HomeCare 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.*(Required) 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. *(Required) 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(Required) Applicant Name: Applicant Date(Required) MM slash DD slash YYYY
