Contact Information
Emergency Contact
Applicant Information
Position(s) Applied for:
1)
2)
Minimum Income Requirements:
Have you worked for Guardian Home Care, Beacon In Home Care and Staffing, or
Country Care before?
If yes, when?
If hired, on what date will you be available for work?
If driving is required of this position:
Do you have a reliable means of transportation?
Do you have a current Idaho driver's license?
Driver's license #:
Are you currently covered by auto liability insurance?
Any you willing to travel, if required by job?
Ability to perform job duties
Are you a U.S. Citizen or Alien with the Right-to-Work in the U.S.?
Please list any reason why might be unable to perform consistently and
promptly any of the job duties:
Have you ever been involved or suspected to be involved in any abuse- or
theft-related crime?
Have you ever been convicted of a felony?
If yes, when?
Have you ever been released from a job due to discipline or being fired?
If yes, why?
License
Type of License (i.e., RN, PT, OT, etc.)
Expiration Date:
License #:
Has your professional license, if required for this position, ever been
revoked?
If yes, please explain:
Have you worked in any state other than Idaho?
If so, what state(s)?
Educational Background
Work History
List in order, most recent employer first
Position
Summary of job duties:
Likes about job:
Dislikes about job:
Starting Salary:$
Ending
Salary: $
Immediate supervisor:
Reason for wanting a job change:
Position
Summary of job duties:
Likes about job:
Dislikes about job:
Starting Salary: $
Ending
Salary: $
Immediate supervisor:
Reason for wanting a job change:
Position
Summary of job duties:
Likes about job:
Dislikes about job:
Starting Salary: $
Ending
Salary: $
Immediate supervisor:
Reason for wanting a job change:
May we contact the employers listed for reference / job history?
If not, please indicate which one(s) you DO NOT wish us to contact and why:
Personal References
Please list three business or school related references. Please do not list
any members of your immediate family.
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Are there any other experiences, skills, or qualifications which you feel are
relevant to this job that have not already been mentioned?
Availability
Please list the times you will be able to work in the matrix below:
Signature
I hereby certify that the answers given by me to all the questions contained
on this application form are true and correct to the best of my knowledge. If
employed by Guardian Home Care, I will comply with all rules and regulations of
the Company. I agree to submit to a physical and/or drug examination (if
required). I also authorize my former employers to give any information they
have regarding me, whether or not it is on their records. I hereby release them
and the Company from all liability for any damage whatsoever for issuing the
same.
I understand that if any fraudulent information is given on this application,
it may be grounds for immediate termination from my position. Guardian is an
Equal Opportunity Employer. I understand that job positions are placed equally
without discrimination because of race, creed, color, religion, sex, national
origin, sexual preference, handicap or age.
In accordance with the Electronic Signatures in Global and International
Commerce Act of 2000, electronic signatures are as valid as paper contracts in
all states, regardless of where the parties live or where the application is
executed. You have the right to request a paper Employment Application from us.
Regardless of whether you make such a request, your electronic signature below
shall remain legally valid and binding.
Signature:
Date:
You will have the opportunity to print your completed application for your
records
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