Application for Employment

Personal Information

Name

Present Address

Telephone

Email

If under 18, please list age

Employment Desired

Position(s) applied for

Days/hours available to work

Salary desired

How many hours can you work weekly?

Can you work evenings?
YesNo

Employment desired
Full-Time OnlyPart-Time OnlyFull or Part-Time

When are you available to start work?

Education

High School Name

College Name

Business or Trade School Name

Professional or Graduate School Name

Work Experience

Please list your work experience for the past five years, beginning with your most recent job held.

Name of Employer

Name of Last Supervisor

Employment Dates

Pay or Salary

Your Last Job Title

Reason for Leaving (Be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions

Other Information

Have you ever been convicted of a felony?
YesNo

If yes, explain number of conviction(s), nature of offense(s), sentence(s), and type(s) of rehabilitation:

Code of Ethics

The Provider agrees to follow and/or enforce for each employee providing services to a client, a written code of ethics that shall include, but not be limited to, the following:

• No consumption of the client's food or drink;

• No use of the client's telephone for personal calls;

• No discussion of one's personal problems, religious or political beliefs with the client;

• No acceptance of gifts or tips from the client or their caregiver;

• No friends or relatives of the employee or unauthorized beneficiaries are to accompany the employee to the client's residence;

• No consumption of alcoholic beverages or use of non-prescribed drugs prior to or during service delivery;

• No smoking in the client's residence;

• No solicitation of money or goods from the client;

• No breach of the client's privacy or confidentiality of records.

Acknowledgement

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I understand that any omission or misstatement of material fact on this application may be grounds for rejection or immediate discharge.

Signature of Applicant

Date

A&M Quality In Home Care is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability.