Gracepoint Home Care Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status. Gracepoint Home Care prohibits all discrimination of any type including those contained in the Americans with Disabilities Act, the Rehabilitation Act and the Civil Rights Act.

Personal Information

First Name *

Last Name *

Social Security Number

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

How did you hear about Gracepoint Home Care? (required)

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Do you have any physical limitations to perform the job applied for? (required)

Yes No

If yes, please explain

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Can you provide documentation of a driver's license? (required)

Yes No

Are you covered by auto liability insurance? (required)

Yes No

What is the name of your insurance company and the expiration date of your policy? (required)

Do you have a reliable means of transportation? (required)

Yes No

Have you ever been or arrested for or convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? Failure to answer this question completely will lead to immediate disqualification for employent. (required)

Yes No

Date available? (required)

Please explain why you are interested in home care and why you feel you would be a good fit for this company (required)

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What days and hours are you available to work for Gracepoint Home Care? Please indicate any days or times you cannot work (required)

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Employment Requirements (required)

Section 2 - Background Check

Do you voluntarily consent to and authorize Gracepoint Home Care to perform a pre-employment investigation and/or background check? (required)

Yes No

Name

Would you consent to a drug screening? (required)

Yes No

If no, please explain

Date

Maiden Name

Date of Birth (required)

Social Security Number (required)

(Numeric Answer Only)

Drivers License Number (required)

(Numeric Answer Only)

Drivers License State of Issue (required)

Current Address (required)

Previous Address

How long have you lived in the state that you're applying in?

(Numeric Answer Only)

I acknowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of employment (required)

Yes No

I certify and declare under penalty of perjury under relevant and federal law that the information contained in my employment application is complete, true, and accurate (required)

Yes No

Section 3 - Employment Verification

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

Section 4 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Years Attended (From/To): (required)

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and years attended (From/To)

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Section 5 - Other Training: Certifications/Licenses

Are you a certified nursing assistant? (required)

Yes No

Are you an RN or LPN? (required)

Yes No

Section 6 - Current Employment

Current Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

Yes No

Section 7 - Employment History

Last Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

Yes No

Section 8 - Reference 1

Name: (required)

Company: (required)

Phone:

Section 9 - Reference 2

Name:

Company: (required)

Phone: (required)

Section 10 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

Relationship: (required)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature