Apply - Caring Matters Home Care of Berks, Bucks, Lancaster, Lehigh & Montgomery

EMPLOYMENT APPLICATION

Today's Date *

PERSONAL INFORMATION

Name (Last Name, First Name) *

Social Security No. *

Present Address *

City *

State *

Zip Code *

Email *

Phone Number *

Cell Number *

Referred By

Emergency Contact Name

Relationship

Phone Number

Have you ever pleaded "guilty or no contest" or been convicted of a misdemeanor or felony? Y / N Yes No

EMPLOYMENT DESIRED

Position *

Date you can start *

Salary desired *

Are you currently employed? Y / N * Yes No

Have you ever applied to this company before? Y / N * Yes No

EDUCATION HISTORY

NAME OF SCHOOL	LOCATION	YEARS ATTENDED	DID YOU GRADUATE?	SUBJECT STUDIED
High School *
College *
Trade, Bus or Correspondence School *

GENERAL INFORMATION

Subject or special study/ research work or special training/ skills

U.S. Military or Naval Service

Rank

RESIDENCY CERTIFICATION

Have you lived in PA for a minimum of at least 2 full years or more? Y / N * Yes No

Please provide address history for the last five years:

Street Name & #	City	State	Zip Code	Years and Dates @ Address
Street Name & #	City	State	Zip Code	Years and Dates @ Address
Street Name & #	City	State	Zip Code	Years and Dates @ Address

PERSONEL REFERENCES *

NAME	RELATIONSHIP	PHONE NUMBER

FORMER EMPLOYERS (List below last three employers, starting with most recent) *

DATE MONTH AND YEAR	NAME & ADDRESS OF EMPLOYER	NAME OF SUPERVISOR & PHONE NO.	SALARY	POSITION	REASON FOR LEAVING
FR.
TO
FR.
TO
FR.
TO

AUTHORIZATION

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal.

"I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company for all liability for any damage that may result from utilization of such information.

"I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disability Act (ADA) and other relevant federal and state laws."