Employment Application

Personal Information
Name:
Present Address:
Permanent Address:
Phone Number:
Are you 18 years old or older:  Yes     No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigrant Status?   Yes     No
Employment Desired
Position
Date you can start:
Salary Desired:
Are you employed now?	Yes     No
If so, may we inquire of your present employer? Yes     No
Ever applied to this company before:  Yes     No
Where
When
Education (Name and Location, Number of Years Attended)
Grammar School
High School
Did you graduate?	Yes     No
College
Did you graduate?	Yes     No
Subjects Studied
Trade, business or correspondence school
Did you graduate?	Yes     No
Subjects Studied
Have you even been convicted, pled guilty or pled "no contest" to a crime (including DUI) in a court other than for a traffic violation? Yes     No
Are you able to perform the essential functions of the job for which you are applying as set forth in the Job Description? Yes     No
Former Employers (List below last three employers, starting with last one first)
Name and Telephone Number
Dates Employed
Salary
Position
Reason for Leaving
Name and Telephone Number
Dates Employed
Salary
Position
Reason for Leaving
Name and Telephone Number
Dates Employed
Salary
Position
Reason for Leaving
Name and Telephone Number
Dates Employed
Salary
Position
Reason for Leaving
References: Give the names of three persons not related to you, whom you have known at least one year
Name
Address
Business
Year Acquainted
Name
Address
Business
Year Acquainted
Name
Address
Business
Year Acquainted
In case of emergency notify:
Name
Address
Telephone Number
I give Volunteer Home Care, Inc. permission to contact former employers for the purpose of obtaining a reference: Yes     No
Date

I acknowledge and understand that certain conditions of hire exist for potential employees of Volunteer Home Care, Inc. I must complete an employee New Hire Health Inventory, TB screening and hepatitis B screening (unless I decline vaccination). I also understand that pre-employment drug screening by urine analysis will be required. Volunteer Home Care, Inc. also reserves the right to perform drug screening by urine analysis at anytime during the course of my employment for just cause. I further authorize Volunteer Home Care, Inc. to obtain a criminal background check and license verification.

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