Application Form

JOB/EMPLOYMENT APPLICATION

Name

Address

Phone

Electronic

Date of Birth

Date of Birth

Position & Pay

Language

Language

Name & Phone Number of Person to contact in the event of an emergency:

Formal

Other Education

Informal Education

Work Limitations

List any work limitations you may have and briefly describe:

Hours & Days Available for Work

Type of Position Preferred

Clients Not Willing/Able to Work With

Transporting Clients

LAST POSITION

2ND TO LAST POSITION

3RD TO LAST POSITION

*Please complete fully. Resume does not substitute for completing this information

Professional Reference

CERTIFICATION

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained this application, as required. Additionally, I authorize former employers, references and any other individual/organizations t provide information to New Day Home Care and I hereby release and discharge any of the above and New Day Home Care from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test, if part of the Agency’s pre-employment policy.

I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.