Career – Peace at Homecare

Date of Application *

First Name *

Middle Name

Last Name *

Phone Number *

Email *

Date of Birth *

Street *

City *

State *

Zip *

Street

City

State

Zip

Driver's License State *

Driver's License Number *

Highest grade completed:

GED:

College:

Degree:

Other:

Please describe any experience you have that may be applicable to the job you are applying for: *

Current and Past Employment (Please List Your Last Three Employers)

Employer 1

Employer's Name: *

Date employment began: *

Date employment Ended: *

Supervisor’s Name/Phone Number: *

Reason for Leaving: *

Employer 2

Employer's Name: *

Date employment began: *

Date employment Ended: *

Supervisor’s Name/Phone Number: *

Reason for Leaving: *

Employer 3

Employer's Name: *

Date employment began: *

Date employment Ended: *

Supervisor’s Name/Phone Number: *

Reason for Leaving: *

Please Give Two PROFESSIONAL References, Not a Friend or Relative:

Reference 1

Name: *

Business: *

Phone Number: *

Years Acquainted: *

Reference 2

Name: *

Business: *

Phone Number: *

Years Acquainted: *

Emergency Contact

Name: *

Relationship: *

Phone Number: *

“I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than it’s president, and then only when in wrong and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.”

Check this box to confirm the above certification:

I agree

Date *

Follow Your Passion

Our Values

Apply to Caregiver Position

Current Address

Mailing Address (If Different)

Are You 18 Years or Older?

Do You Have Any Friends or Relatives Who Currently Work With Us?

Do You Have a Valid Driver's License?

Are You Able to Use Your Own Car? *

Are you able to use your own car to transport clients? *

Are you a U.S. citizen or approved to work in the United States? *

Do you have any reservations about working around cats, dogs, or other pets? *

Are you employed now? *

Have You ever been arrested? *

Have You ever been convicted of a criminal offense (felony or misdemeanor)? *

Can you work overnight shifts? *

Can you work weekends? *

Education/Special Training

Certifications you have:

Current and Past Employment (Please List Your Last Three Employers)

Employer 1

Employer 2

Employer 3

Please Give Two PROFESSIONAL References, Not a Friend or Relative:

Reference 1

Reference 2

Emergency Contact

Check this box to confirm the above certification: