aregivingposition.com
APPLICATION FOR EMPLOYMENT CONSIDERATION
PLEASE READ THE FOLLOWING BEFORE FILLING OUT THIS APPLICATION FORM:
The Client's Parents are acting on behalf of client in finding potential applicants for the position of personal assistant in her daily tasks, and do not discriminate in recruitment, training, promotion or other employment practices on the basis of age, race, sex, color, religion, national origin, physical or mental handicap, veteran status or any other basis that is prohibited by federal, state, or local law. Ultimately potential applicants will be redirected to the agency managing the actual employment and subject to the hiring practices and policies of that agency. No question in this application is intended to secure information to be used for such discrimination. This application will be given every consideration, but its receipt does not imply that the applicant will be employed by the agency in charge of managing client’s DHS hours that have been allocated to her through the CDS payroll management.
DATE: (dd-mm-yyyy)
Name in full:
Date of Birth:
Home Phone:
Cell Phone:
Social Security:
Drivers License
State:
Drivers License
Number:
Have you ever used another name or Social Security number for identification:
Present Address:
City:
State:
Zip Code:
Email Address:
Do you currently have any commitments or obligations that would take you away from your work either scheduled or non scheduled?
If so please explain:
EMPLOYMENT HISTORY:
If you are presently employed may we contact your employer?
IMPORTANT! Give name and phone number of your last ten (10) year employment history, beginning with your present or last employer:
Name of Employer
City,State
Phone
Job Title
Date From
Date To
Reason For Leaving
PERSONAL INQUERY
Will you abide by the safety rules?
Have you ever been arrested or convicted of a criminal offense ?
If yes complete the following:
DATE:
NATURE OF CONVICTION:
WHERE:
DISPOSITION OF OFFENSE:
Have you ever been convicted of a Traffic Law Violation (do not list Parking Violations)?
If yes, please explain
Note: Information regarding conviction record will not necessarily bar any applicant from employment but will be reviewed in light of all surrounding circumstances, nature and seriousness of violation, rehabilitation, relationship of offense to employment and federal, state and local laws.
EDUCATION:
Name
High School:
Location
College:
Special Studies
Graduate
Year
Other:
What are your long term objectives & goals?
PERSONAL REFRENCES:
( please don’t use relatives )
Name
Address
Phone #'s
Relationship
How Long
If you move into the house, who will be living with you?
Do you have any pets?
If so please explain:
When would you be available to start?
If hired what duration of time are you looking to be employed at this job?
Do you cook?
Please read the following carefully
In connection with my application with the clients parent's, I fully understand this release acknowledges that the clients parent's are acting on the behalf of client in finding her an assistant and may, after an opportunity of employment ( through an agency) is made to me, or at any time while I am employed by an agency, conduct a public record/research report containing information for verification of prior employment, academic achievement, medical and financial history, use of a motor vehicle, general background and personal character. This release shall not be limited in its scope or purpose. I authorize and request all persons, schools, businesses, corporations, courts, law enforcement, health care providers, armed forces, employment commissions and government agencies to release said information without restriction or qualification. I authorize a Photostat of this release (by fax, e-mail, or hand delivery) to be considered as effective and valid as the original. All results will be proprietary and kept confidential, and will not be provided to any parties other than the clients parent's, client, Employment related agencies and/or its legal representatives. I am aware that I have the right to request the nature and scope of the results, as reported from the clients parent's. I voluntarily waive all recourse and release the requested parties from liability for complying with this request/release. I agree that I will submit to a physical, urinalysis and/or blood test or other examinations requested by the clients parent's and/or client at any time prior to or subsequent to my employment by an agency. I authorize any medical provider or drug screening company to provide my test results to the clients parent's, client and/or employer with such information as reasonably requested, subsequent to an opportunity for employment. I further understand that my employment (managing agency) is for no fixed time and may be discontinued with or without cause or notice by myself, the clients parent's and/or client. I also understand that no firearms, alcohol or drugs are permitted at my place of work or on any property owned by the clients parent's and that either being under the influence of illicit drugs or alcohol or having identifiable traces of them in my system during working hours is strictly prohibited. If medication is prescribed by a doctor that will impair my ability to work, I am required to so notify the clients parent's, and/or client in writing of the specific medical problem and the exact drug that has been prescribed. This Agreement supersedes any and all other agreements, either oral or written, between the parties referenced herein with respect to the Application for consideration of employment (by the managing agency) of me by the clients parent's, and/or client and contains all covenants and agreements between the parties regarding such employment in any manner what so ever. I understand that if I am hired, I am the employee of the managing agency and that the clients parent's are strictly acting as the liaison for client personally. I understand that I have no business relationship with the clients parent's other than the use of the House that I would reside in and will adhere to the rules of living there under a separate agreement. I further agree that I shall in no way make claim(s) of any kind regarding the clients parent's, and/or client or their predecessors for any reason and . I further understand that I am not covered by any worker’s comp, or liability insurance provided by the clients parent's, and/or client or predecessors and indemnify and save harmless and will defend the clients parent's, and/or client and their agents and/or representatives from and against any and all liabilities, obligations, damages, penalties, claims, costs, charges and expenses, including without limitation, reasonable attorneys' fees and court costs, which may be imposed upon or incurred by or asserted against the clients parent's, and/or client and/or their agents by reason of any of the following occurring when I am (i) on or in possession of any of the property belonging to them. (ii) any negligent or otherwise wrongful acts or omission on my part or any of my agents, contractors, subcontractors, servants, employees, subtenants, or invitees; (iii) any accident, injury or damage to any person or property occurring in, on or about the property of the clients parent's, and/or client, caused in whole or in part by me or any of my employees, agents, associates, contractors, or invitees., (iv) any failure on my part to perform or comply with any covenant, agreement, term, rule, provision, condition or limitation contained in this Agreement on its part to be performed or complied with; and (iv) any accident, injury or damage to any person Application or property occurring in, on or about the property of the clients parent's, and/or client, caused by any animal that belongs to or is or should be in the possession or control of me or any of my agents, contractors, associates, subcontractors, servants, employees, subtenants, or invitees. I declare that the answers to the questions on this application are correct and that any misstatement of fact or omission will be cause for dismissal or rejection. I have carefully read the information on this form, and realize that I had the opportunity to ask questions about it.