CAREER – Precious Angels Home Care Services

Position Applied For

Application Date:

Have you received and read the Job Description and been informed of the responsibilities of the position for which you are applying?

Yes
No

Name

Social Security No :

Address:

Telephone:

Date:

Are you over 21 years of age?

Yes
No

Email *

Special Interest and Aptitudes: (Please list volunteer work, training, experience or areas of special interest that would better qualify you for this position.:

PROFESSIONAL AND VOCATIONAL

List below your las ten years Employment History. Begin with your most recent employer.

DATES WORKED

NAME AND ADDRESS OF

MONTH AND YEAR

PRESENT OR MOST RECENT EMPLOYER

JOB TITLE and/or POSITION

Types of Duties

Reason for Leaving:

May we contact this employer:

Yes
No

If no. reason:

DATES WORKED

NAME AND ADDRESS OF

MONTH AND YEAR

PRESENT OR MOST RECENT EMPLOYER

JOB TITLE and/or POSITION

Types of Duties

Reason for Leaving:

May we contact this employer:

Yes
No

If no. reason:

DATES WORKED

NAME AND ADDRESS OF

MONTH AND YEAR

PRESENT OR MOST RECENT EMPLOYER

JOB TITLE and/or POSITION

Types of Duties

Reason for Leaving:

May we contact this employer: (copy)

Yes
No

If no. reason:

WORKING CONDITIONS/REQUIREMENTS: Are you able to perform, with or without reasonable accommodations, essential functions for the job for which you are applying? If an accommodation is required, how much would you perform the essential functions and with what accommodations?

DRIVER’S LICENSE INFORMATION

Precious Angel Home Care Services Inc. requires a valid Georgia Driver’s License, as transportation of clients, residents and company needs are required.

Driver’s License Exp Date:

CRIMINAL RECORD INFORMATION: Have you ever shown by credible evidence (such as a decision of a court or jury, or a department investigation or other reliable evidence) to have abused, neglected, sexually exploited, or deprived a child of adult or to have subjected any person to serious injury as a result of intentional or grossly serious injury as a result of intentional or grossly negligent misconduct as evidence by an oral or written statement to this effect obtained at the time of application:

I hereby apply for employment with Precious Angel Home Care Services Inc.
I certify that my answers are true and complete to the best of my knowledge.
I agree to abide by all rules and requirements set forth by Management of Precious Angel Home Care Services Inc. as govern by the rules, regulations of the law and notify the appropriate authorities of any criminal charges and convictions of child abuse, neglect or endangerment that may occur during my period of employment with the home and which may have occurred in my previous employments.
I certify that, to the best of my knowledge, the statements given on this employment application truly represent my background and experience
I hereby authorize investigation of any and all of the statements contained in this application and understand that misrepresentation or omission of pertinent facts called for may constitute grounds for dismissal,