Employment Opportunities

If you are seeking a caregiver position with a stable home care agency to grow with, please take a moment to complete our application.

EMPLOYMENT OPPORTUNITIES

Step 1 of 5

20%

ANGELIC HEARTS HOME CARE
SERVICES, LLC

APPLICATION FOR

EMPLOYMENT

INDEPENDENT CONTRACTOR

Angelic Hearts Home Care Services, LLC. (the "Company") is an equal opportunity/affirmative action employer and contractor. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, or physical or mental disability.

Name

Last Name First Initial

Social Security #

Other Name(s) Used

Date of Birth

MM slash DD slash YYYY

Address

Cell Phone #

Home Telephone #

Position Applied For

Salary Desiredd For

Email Address

Referred By

Are you at least 18 years old?

Yes

If under 18, do you have a work permit?

Yes

Emergency Contact Number:

EDUCATION

Circle Highest Grade Completed	High School	9	10	11	12
	College, Trade or Business	1	2	3	4
	Graduate Studies	_	_	_	_

High School

Address

Major Studies

Degree, Diploma, License or Certificate

College University

Address

Major Studies

Degree, Diploma, License or Certificate

Vocational, Business, Other

Address

Major Studies

Degree, Diploma, License or Certificate

List Any Professional Licenses, or certifications including license numbers and expiration dates

Other Special Knowledge, Skills or Qualifications

For Clerical Applicants Only:

Do you type?

Yes

WPM

Computer Skills (Hardware/Software)

EMPLOYMENT HISTORY

List all employed and/or contracted positions for the past 10 years, starting with the most recent position. All information must be completed. You may attach a resume in place of completing the required information.

Employed From

MM slash DD slash YYYY

Employer Name

Supervisor Name

Starting Salary

Employed Until

MM slash DD slash YYYY

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

Employed From

MM slash DD slash YYYY

Employer Name

Supervisor Name

Starting Salary

Employed Until

MM slash DD slash YYYY

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

Employed From

MM slash DD slash YYYY

Employer Name

Supervisor Name

Starting Salary

Employed Until

MM slash DD slash YYYY

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

Employed From

MM slash DD slash YYYY

Employer Name

Supervisor Name

Starting Salary

Employed Until

MM slash DD slash YYYY

Employer Address

Supervisor Phone #

Ending Salary

Job Title

Reason for Leaving

Duties & Responsibilities

GENERAL

May we contact your current employer for references?

Yes

If hired as an employee, will you be able to work overtime?

Yes

Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation?

Yes

Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or seals by court? (A “yes” response does not automatically disqualify your application.)

Yes

CERTIFICATION & AUTHORIZATION

The above information is true and correct. I understand that, in the event of my employment by or contract with the Company, I shall be subject to dismissal if any of the information I have given in this application is false or misleading, or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.

I authorize the Company to inquire into my educational, professional and past employment or contract history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment or contracting decision was made on the basis of such information.

I understand that nothing in this employment application, the granting of an interview or my subsequent association with the Company, is intended to create an employment contract between myself and the Company. On the contrary I understand and agree that, if hired/contracted, my employment/contract will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing.

If employed, I will be required to provide original documents, which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9.

I hereby acknowledge that I have read and agree to the above statements.

REFERENCE VERIFICATION

Reference Name:

Address:

Telephone Number:

Fax Number:

I have applied for contract with Angelic Hearts Home Care Services, LLC. I authorize you to respond to the questions below, and any telephonic queries from Angelic Hearts Home Care Services, LLC, so they may act on my application. I release you from all liability in supplying this information regarding my employment with you.

I worked for you from

MM slash DD slash YYYY

as a/an

Print Applicant's Name:

Applicant's Signature:

Date

MM slash DD slash YYYY

REFERENCE VERIFICATION

Reference Name:

Address:

Telephone Number:

Fax Number:

I worked for you from

MM slash DD slash YYYY

as a/an

Print Applicant's Name:

Applicant's Signature:

Date

MM slash DD slash YYYY

Signature

Date

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

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