Application Form - A Legacy of Love Homecare LLC

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Applicant

Name*

First Name Last Name

Address*

Home Address Address Line 2 (Ste, Bldg) City State Zip Code

How long have you been at this address?*

Marital Status:*

Married

Single

Widowed

Divorced

Partnered

Separated

Phone*

Email*

Driver's License Number and STATE*

Social Security Number:**

Date Of Birth*

MM slash DD slash YYYY

Please Screenshot or Scan a copy of Your Driver's License to us - FRONT & BACK

Drop files here or

Max. file size: 512 MB.

Emergency Contact

Who should be contacted in case of an emergency?

Contact Name*

Address*

Street Address Address Line 2 City State Zip Code

Relationship to you*

Phone*

General Information

Job/Position Applying For*

Number of Hours you are interested in (Full or Part Time)*

Salary/Wage Desired (per hour)*

1. How did you learn about our company?*

2. Do you have any friends or relatives who work here? If yes, please list here*

3. Are you willing to work any shift, including nights and weekends? Yes or No - Explain*

4. If you are offered employment, when would you be available to begin work?*

5. Have you ever been convicted of a felony or misdemeanor? Yes or No If Yes, provide the following information: **

Yes

Yes, I was convicted of ______________________________ on ____________ (date) in _________________ (city), _______________ (state) ______ (NOTE: THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.) **

Applicant Skills

List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and include a number 0 -5 that corresponds to your ability for each particular skill. Skill / # of years / Skill level

(One represents poor ability, while five represents exceptional ability.)

Skill #1:

Skill #2:

Skill #3:

Skill #4:

Skill #5:

Skill #6:

Skill #7:

Skill #8:

Skill #9:

Skill #10:

Feel Free to add any additional skills or anything you feel would add to your experience

Applicant Employment History

(List your current or most recent employment first. Please list all jobs (including self-employment and military service) that you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue in the notes section below.)

Employer Name*

Job*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Supervisor*

Reason for Leaving*

Employer Name*

Job*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Supervisor*

Reason for Leaving*

Employer Name*

Job*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Supervisor*

Reason for Leaving*

Notes for Additional Employer Information (if applicable)

Education / Training

High School - Did you graduate?*

Yes

If NO to High School graduate, do you have a GED? Yes or No

Yes

Name and Address of High School: (enter n/a if not applicable)*

Do you have any additional Training or College/University Education? - If yes, provide the following*

Yes

Name and Address of School: (enter n/a if not applicable)*

Did you receive a degree? Yes or No If yes, degree(s) received*

Yes

Degree(s) Received: (enter n/a if not applicable)*

Other Training (graduate, technical, vocational): (enter n/a if not applicable)*

Please indicate any current professional licenses or certifications that you hold: (enter n/a if not applicable)*

Awards, Honors, Special Achievements: (enter n/a if not applicable)*

3 References

List one relative and any two non-relatives who would be willing to provide a reference for you.

Name of Relative*

Phone*

Address*

City/State/Zip*

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Name of Relative*

Phone*

Address*

City/State/Zip*

This field is hidden when viewing the form

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Name of Relative*

Phone*

Address*

City/State/Zip*

Additional Information

(Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer or anything you feel we need in consideration of your employment with us.)*

Certification

Consent*

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for the rejection of my application or, if employment commences, immediate termination. I authorize A Legacy Of Love Homecare, LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION, AND I UNDERSTAND AND AGREE TO ITS TERMS.*

Type Your Full Name: (Note: A digital or electronic signature is considered legally valid and binding, as it provides a secure and verifiable method of signing documents electronically. These signatures comply with international standards and regulations, ensuring authenticity and integrity in digital transactions.)**

Signature*

Date

MM slash DD slash YYYY

Applicant Availability Form

Below please provide your availability including the days and times you would be available to work.

Check ALL Days of the Week that you are available to work.*

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Check all Shifts that you are available to work.*

Shift 1 8am - 12noon

Shift 2 12noon - 4pm

Shift 3 4pm - 8pm

Shift 4 8pm - 12am

Shift 5 12am - 4am

Shift 6 4am - 8am

How many hours are you interested in working each week?*

Are you available for Short Notice Shifts for call-offs etc?**

Yes

Please share or explain any details about shifts you are interested in or would be available for short notice etc:

Application For Employment

Please complete the entire application.

Employer Information

Applicant

Emergency Contact

General Information

Applicant Skills

Applicant Employment History

Education / Training

3 References

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Additional Information

Certification

Applicant Availability Form

Application For Employment

Please complete the entire application.

Employer Information

Applicant

Emergency Contact

General Information

Applicant Skills

Applicant Employment History

Education / Training

3 References

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Additional Information

Certification

Applicant Availability Form

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