Would You Like To Work For Our Company?

Employee Information

Full-TimePart-Time

Have You Ever Applied At Our Company? YesNo

Are You At Least 18 Years Old? YesNo

If Hired, Are You Able To Submit Proof That You Are Legally Eligible For Employment In The United States?YesNo

Are You Able To Perform The Essential Functions Of The Job Position You Seek With Or Without Reasonable Accommodation?YesNo

What Reasonable Accommodation, If Any, Would You Request?

Have You Ever Been Convicted Of A Felony Or Misdemeanor?YesNo

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.

Employer 1

Employer 2

Employer 3

Military Service

Have You Served In The Military?YesNo

References

Reference 1

Reference 2

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

Certification

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences immediate termination.

I authorize Associated Family Home Care, Inc. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Administrator, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Associated Family Home Care, Inc., except in a specific written contract of employment signed on behalf of the organization by its Administrator, has the power to alter or vary the voluntary nature of the employment relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.