Careers Form

Date

Last Name *

First Name *

Middle Initial

Address *

City

State

Zip Code

Phone *

Position applied for

Available to Work

Full Time

Part Time

Are there any days or hours you would be unable or unwilling to work?

Yes

No

Date available to start

Please Specify

Salary Desired

Least accepted salary

Do you have the legal right to be employed in the united states?

Yes

No

If you are under 18, will you be able to furnish a work permit after employment?

Yes

No

N/A

How did you hear about Atlas Home Care Services LLC family services?

Drivers License Information

Date Issued

Expiration Date

SSN Number

Work History

LIST THE NAMES OF ALL EMPLOYERS, GIVING THE MOST RECENT POSITION FIRST. PLEASE GIVE THE MONTH AND YEAR FOR EACH POSITION LISTED. IN ADDITION, BE SURE TO LIST ALL HEALTH OR HUMAN SERVICE PROVIDERS FOR WHICH YOU HAVE WORKED. IF YOU NEED ADDITIONAL SPACE, PLEASE CONTINUE ON ANOTHER SHEET OF PAPER.

Employer Name *

Address

Phone

Job Title

Supervisor

Reason for leaving

Employment Dates
From

To

Salary Started

Salary Ended

Duties

Employer Name

Address

Phone

Job Title

Supervisor

Reason for leaving

Employment Dates
From

To

Salary Started

Salary Ended

Duties

Employer Name

Address

Phone

Job Title

Supervisor

Reason for leaving

Employment Dates
From

To

Salary Started

Salary Ended

Duties

Have you ever been disciplined or discharged by an employer for client abuse or neglect?

Yes

No

Have you ever been convicted (or plead guilty) of any crime (felony, misdemeanor or summary offense), including driving while intoxicated?

Yes

No

Please Explain

(INFORMATION REGARDING CONVICTIONS WILL NOT NECESSARILY DISQUALIFY YOU FOR EMPLOYMENT, BUT WILL BE REVIEWED IN LIGHT OF THE DUTIES AND RESPONSIBILITIES OF THE POSITION BEING SOUGHT) DRIVER’S LICENSE NUMBER & STATE* CURRENTLY VALID? Yes No *A VALID DRIVER’S LICENSE AND ACCEPTABLE DRIVING RECORD ARE REQUIRED FOR MANY POSITIONS

Education

High School

Name of School

Address

Years Completed

1

2

3

4

Graduated

Yes

No

Major

Degree

Undergraduate College

Name of School

Address

Years Completed

1

2

3

4

Graduated

Yes

No

Major

Degree

Graduate/Professional

Name of School

Address

Years Completed

1

2

3

4

Graduated

Yes

No

Major

Degree

Professional licenses and/or certifications

List any professional licenses

License Number

Has your professional license ever been suspended or revoked?

Yes

No

Please explain

List any relevant certifications

Military Experience

U.S. military service?

Yes

No

Branch

Date Entered

Date Discharged

Describe any job related training received in u.s. military

Related Information

PLEASE LIST ANY OTHER QUALIFICATIONS, PROFESSIONAL ORGANIZATIONS, AND/OR VOLUNTEER EXPERIENCES THAT ARE APPLICABLE TO THE POSITION FOR WHICH YOU ARE APPLYING. YOU MAY EXCLUDE ONE WHOSE NAME WOULD INDICATE THE RACE, ELIGION, CREED, COLOR, NATIONAL ORIGIN, OR ANCESTRY OF ITS MEMBERS.

References

If you worked for previous employers under another name, please give that name

Are you currently employed?

Yes

No

May we contact your present employer?

Yes

No

Give three work-related references

Name *

Address

Phone

Occupation

Name

Address

Phone

Occupation

Name

Address

Phone

Occupation

Authorization and release of information

I hereby give Atlas Home Care Services LLC, hereafter known as AHCS, the right to thoroughly investigate my past employment, education, police record, activities, and I release from all liability all persons, companies, and corporations supplying such information. I indemnify AHCS against any liability which might result from conducting such an investigation.

I understand that any false answers or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between AHCS and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon AHCS unless made in writing by the President. If any employment relationship is established, I understand that I have the right to terminate my employment at any time for any reason or no reason at all, with or without prior notice, and that AHCS retains the same right.

Name of Applicant *

Date