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Home Care Professionals

209B RAILROAD ST N. AHOSKIE, NC 27910
EMAIL: [email protected]
PHONE: (252) 209-6005
FAX: (252) 209-8616

Employment Application
INSTRUCTIONS

If you need help filling out this form or any phase of the employment process, please notify us and every effort will be
made to accommodate your needs. Your application will not be considered if incomplete.

Applicant Information

Full Name: Date:

Last First M.I.

Address:
Street Address Apartment/Unit #

City State ZIP Code

Phone: Email

Date Available: Social Security No: Starting Rate:$

Position Applied for:

Check all that apply:

Full-time Part-Time Weekends Mornings Afternoon Evening

By who were you referred? _________________________________________________________________________

YES NO
Are you at least 18 years of age?

Eligibility

Home Care Professionals, LLC will only work with U. S. citizens and aliens lawfully authorized to work in the U.S.

YES NO YES NO
Are you a citizen of the United States? If no, are you authorized to work in the U.S.?

YES NO
Have you ever worked for this company? If yes, when?

Are you capable of performing, with or without reasonable accommodations, the essential functions of the job for which
you have applied?
YES NO
If no, explain:
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This information will be reviewed for job relatedness and will not necessarily disqualify an applicant from employment.

YES NO
Have you ever been convicted of a felony?
If yes, explain:

Education

High School: Address:

YES NO
From: To: Did you graduate? Diploma:

College: Address:

YES NO
From: To: Did you graduate? Degree:

Other: Address:

YES NO
From: To: Did you graduate? Degree:

Caregiving References
Please list three professional caregiving references.

Full Name: Time Known:

Company: Phone:
Address:

Full Name: Time Known:

Company: Phone:
Address:

Full Name: Time Known:

Company: Phone:
Address:

Previous Employment

Company: Phone:
Address: Supervisor:

Job Title: Starting Salary:$ Ending Salary:$

Responsibilities:

From: To: Reason for Leaving:

May we contact your previous supervisor for a reference? YES NO

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Company: Phone:
Address: Supervisor:

Job Title: Starting Salary:$ Ending Salary:$

Responsibilities:

From: To: Reason for Leaving:

YES NO
May we contact your previous supervisor for a reference?

Company: Phone:
Address: Supervisor:

Job Title: Starting Salary:$ Ending Salary:$

Responsibilities:

From: To: Reason for Leaving:

YES NO
May we contact your previous supervisor for a reference?

Military Service
Branch: From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.

Signature: Date:
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Please Read Carefully

"I certify that the facts contained in this application are true and correct without any consequential omissions of
any kind. I understand that if I am employed, and false, misleading or otherwise incorrect statements made on this
application for or during any interviews may be grounds for my immediate discharge.
I hereby authorize Home Care Professionals to contact any company or individual it deems appropriate to
investigate my employment history, character and qualifications and I give my full and complete consent to their
revealing any and all information they wish as a result of this investigation.
In addition, I hereby waive my right to bring any cause of action against these individuals for defamation, invasion
of privacy or any other reason because of their statements. I agree that if I am employed, I will abide by all the
rules and regulations of is Organization. I also understand that my employment is "at-will" and may be terminated
by myself or by Home Care Professionals at any time for any reason at all, with or without advance notice. "This
waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the
Americans with Disabilities Act (ADA) and other relevant federal and state laws.

No representative or employee of Home Care Professionals, with the exception of the Executive Director, has the
authority to enter into any contract or agreement to the contrary, and then only if such commitment is in a written
document signed by the Director and the employee.

I acknowledge that I have read and understand these terms.

Signature: Date:

HOME CARE PROFESSIONALS IS AN EQUAL OPPORTUNITY EMPLOYER

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Skills and Abilities

Do you have a valid driver’s license?
YES NO

Driver’s License #: ____________________________________________________________

In the past three years have you received moving violations, or been involved in any vehicle accidents that were your
fault?

YES NO

Remarks

Please add any statements which you feel may help to clarify answers to the questions in this application. Also, you
may add job-related volunteer activities or knowledge, skills and abilities as they relate to the job for which you are
applying. (You may exclude information which reveals race, religion, age, disability or other protected status.)
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AUTHORITY FOR RELEASE OF INFORMATION

I authorize the North Carolina Department of Justice through the STATE BUREAU OF
INVESTIGATION, Special Operations Division, to perform a fingerprint search of the State’s criminal
history record file and, if applicable, a fingerprint search of the FEDERAL BUREAU OF
INVESTIGATIONS files for a national criminal history record check in connection with my employment
or volunteer services with Home Care Professionals, LLC pursuant to N.C.G.S 114-19.3,131D-40 or
131E-265

(Type or Print clearly)

Last Name First Middle Maiden

_____________________ ___________________ ______________ _____________

Social Security Number Date of Birth Sex Race

(Optional*)

______________________ __________________ _____________ _____________

I understand that the North Carolina State Bureau of Investigations, Special Operations Division, and its
officials and employees shall not be held legally accountable in any way for providing this information
to the above named agency, and I hereby release said agency and persons from any and all liability
which may be incurred as a result of furnishing such information. I further understand that the agency
cannot provide a hard copy of the results of this criminal history record check to me.

*Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be
utilized to assist the accurate identification/exclusion of possible criminal history records.

Applicant’s/Employee’s Signature

________________________________________________________

Date

___________________________________

This form must be maintained on file with the above named agency for one year. Do not mail this form or a copy of
this form to the State Bureau of Investigation.
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FOR OFFICE PERSONNEL USE ONLY