Senior Solutions In-Home Care

You are applying for an In-Home Care & Services position with Senior Solutions

Desired Position

Location

St. Andrew's Senior Solutions

Date Of Application

Contact Information

Name

Address

Phone

Email

Referral Source

Workplace Information

Have you ever been employed here before?

Yes No

Salary Requirements

Desired Salary (hourly rate)

Type Of Employment Desired

Full-Time

Part-Time

PRN

1st Shift

2nd Shift

3rd Shift

Nights

Weekends

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Employer's Name

Current or Last Position

Employer's Address

Employer's Phone Number

Supervisor's Name

Start Date

End Date (if applicable)

Current or Latest Salary (Hourly Rate)

Educational Background

School Name and Degree Earned #1

School Name and Degree Earned #2

Licenses & Certifications

Licenses & Certifications #1

Licenses & Certifications #2

Licenses & Certifications #3

Reference Names

Reference #1

Reference Name #2

Reference Name #3

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions, and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive anyand all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration of employment on any basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete and I-9 Form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect will be sufficient cause to, (i) eliminate me from the further consideration for employment or, (ii) may result in my immediate discharge from the employer’s service, whenever it is discovered.

I certify that I have read, fully understood and accept all terms of the forgoing Applicant Statement.

Application For Employment