Job Application

Please fill out all of the sections below:

Date:

Availability Sheet

Please put your name and the times you can work. Your schedule will be made according to your availability. Once your availability is made you will not be able to change it for 60 days unless it is approved by someone in the office. You must work every other weekend.

Name:

List

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Are you willing to travel?

Yes

Your Signature

Date

Applicant information

Applicant Name

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone Number

Email Address

DOB

State

Exp. Date

Emergency Contact

Name

Relationship

Phone Number

Employment Position

Position applying for:

How did you hear about us?

If hired, what date can you start working?

Have you ever worked for this agency?

Yes

Have you ever been convicted of or pleaded no contest to a felony within the last five years?

Yes

“Yes” answer does not automatically disqualify you from employment. Please describe the crime – state the nature of the crime(s) when and where convicted, and the disposition (final settlement) of the case:

Are you able to perform the essential functions of the job for which you are applying?

Yes

Personal Information

Availability Sheet

Are you a citizen or approved to work in the U.S.?

Yes

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

High School:

Year Graduated:

Diploma

GED

Vocational School/Specialized Training

Year Graduated:

Degree Earned:

College

Year Graduated:

Degree Earned:

Military

Are you a member of the Armed Services?

Yes

What branch of the military did you enlist?

What was your military rank when discharged?

How many years did you serve in the military?

Previous Employment

Employer Name

Job Title

Supervisor Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Telephone

Dates Employed

Reason for leaving

Employer Name

Job Title

Supervisor Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Telephone

Dates Employed

Reason for leaving

Employer Name

Job Title

Supervisor Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Telephone

Dates Employed

Reason for leaving

May we contact the Employer?

Yes

References

Name

Relationship

How long have you known this person?

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Name

Relationship

How long have you known this person?

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Name

Relationship

How long have you known this person?

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

I certify that the information contained in this application is true and complete. I understand that false information may be grounds for not being hired and/or immediate termination of employment if hired. I understand that false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing of a BCI background check. I authorize the verification of any and all information listed above.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERATAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

Signature

Date

Dignity in Home Care Services LLC
Phone: +123 456 7890

Email: dignityinhomecare@demolink.com

Required Documents

Driver's License
Social Security Card
TB Test
Certification/License
CPR basic life support American Hearts Association

Upload the documents below

Driver's License

Drop files here or

Max. file size: 1 GB.

Social Security Card

Drop files here or

Max. file size: 1 GB.

TB Test

Drop files here or

Max. file size: 1 GB.

Certification

Drop files here or

Max. file size: 1 GB.

CPR basic life support American Heart Association

Drop files here or

Max. file size: 1 GB.

Choose File

Upon hiring, you will receive a confirmation email with request to upload additional documents

Choose File

Upon Hire Fill out, sign and upload the following:

W-4 Form

Drop files here or

Max. file size: 1 GB.

IT-4 Form

Drop files here or

Max. file size: 1 GB.

I-9 Form

Drop files here or

Max. file size: 1 GB.

Direct Deposit Authorization Form

Drop files here or

Max. file size: 1 GB.

Background Authorization Form

Drop files here or

Max. file size: 1 GB.

The Ohio Administrative Code (5123:2-.05) requires that home health care companies ascertain from applicants for employment that have not been convicted, plead guilty of the offenses listed below. Your signature below indicates that you have not committed nor plead guilty to:

Aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, failing to provide for a functionally impaired person, aggravated menacing, patient abuse and neglect, kidnapping, abduction, criminal child enticement, rape, sexual battery, unlawful sexual conduct with a minor, gross sexual imposition, voyeurism, public indecency, compelling prostitution,promoting prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually oriented material involving a minor, illegal use of a minor in nudity-oriented material or performance, aggravated robbery, robbery, aggravated burglary, burglary, unlawful abortion, endangering children, contributing to unruliness or delinquency of a child, domestic violence, carrying concealed weapon, having weapons under disability, improperly discharging a firearm at or into a habitation or school, corrupting others with drugs, drug trafficking, illegal administration or distribution of anabolic steroids, placing harmful objects in food or confection, child stealing, possession of drugs. Felonious sexual penetration.

Type

have the content of this addendum to my application for employment with Dignity in Home Care Services LLC, I also understand

that I am required by law to notify Dignity in Home Care Services LLC within 14 days if I receive formal charges or convictions or make a guilty plea to any of the disqualifying offenses listed above.

Applicants Signature/Date

Pre Interview Questions

Last

First

Middle

Date

Address

City State / Province / Region ZIP / Postal Code Country

E-Mail address

Date Available:

Position(s) applied for:

Type of employment desired:

Full-Time

Part-Time

Casual/Occasional

Contract

Driver's License & Reliable Transportatio :

Yes

First Aid/CPR:

Yes

Update

Availability:

1. Can you tell me how many days per week and / or hours per day you are looking for?

2. Are there any restrictions in the number of hours , days per week or special consideration in scheduling?

Let's start by reviewing your application

(Ask any questions needed in order to get missed or incomplete information from the candidate's application)

Let's talk about the position you are applying for - (candidate reviews the job description, including physical requirements, education and/or training requirements and any other relevant conditions of employment.)

1. Does the position described above with its requirements sound like something you are still interested in?

(This is potential exit point in the interview if the candidate indicates lack of interest or does not meet the requirements)

2. We all have Strengths and areas of opportunity for improvement . What would you say yours are?

a. Strengths

b. Opportunities

3. What efforts have you made in the past 12 months to address or improve your skills?

4. What plans do you have in the next 12 months?

(YOUR COMPANY is an organization focused on continued growth and improvement-look for employees who are motivated to improve current skill levels, reach higher levels of accreditation and/or ongoing self improvement)

5. We all make mistakes. Tell me about a time when you made a mistake? How did you handle it?

(look for acknowledging the mistake to self and others, taking responsibility and participation in the solution)

6. Tell me about your biggest challenge at work. What was it and how did you overcome it?

(look for self motivation, seeking solution that worked for all "win/win" )

7. Tell me about a time when you saw an opportunity and took steps to take advantage of it?

(Look for initiative to capitalize on the opportunity and follow through on results)

8. Tell me about your relationship with your last supervisor? What would you say his/her strengths were? What were the weaknesses?

9. What would he/she say yours were?

(Look for open communication, ability to work with others-even under difficult circumstances)

10. What do you hope to realize/gain from this position if you are successful.

(look for employee who wants to learn , master a skill / position and seek additional level of responsibility etc.)

11. We all have hot buttons. What would you say yours are and how do you respond?

(Communication-look for values and management of reactions with overall goal toward respect of self and others.)

12. Describe a situation were you had a serious difference of opinion with another co-worker or supervisor. How did you handle it and what was the final outcome.

(Look for ability to see other's point of view, open communication and resolution that allowed for ongoing productive working relationship without compromising customer service and work environment.)

13. Describe a time when you were asked to do something that was against your company policy or rules.

How did or would you handle it? (If candidate does not have an example, it's advisable to make up an example. Looking for integrity and commitment to principles, company policy etc.)

14. Under what circumstances would you say it is acceptable to break a confidence of another co-worker or customer?

(Look for level of trust-only breaking if another person is at risk of danger or company would be negatively affected).

15. Why do you feel you are the right person for this position? What do you think you would bring to the team?

(Look for strong interpersonal skills, professionalism and self motivated to achieve results)

16. How important is "balance" in your life? What would you say your current level of satisfaction with balance is?

(Look for candidates with well rounded balance including family, work, physical exercise, spiritual and emotional balance - i.e. hobbies etc.)

17. How would you respond if a client were verbally and physically aggressive towards you?

(Look for understanding, reasoning and ability to deal with conflict but also ability to communicate field problems to office)

18. A client refuses to comply with care for example won't take a bath or take medications. How would you deal with this?

(Look for ability to work through adversity to complete task.)

NOTES:

Diginity In Home Care

Please fill out all of the sections below:

Availability Sheet

Applicant information

Emergency Contact

Employment Position

Personal Information

Availability Sheet

Job Skills/Qualifications

Military

Previous Employment

References

Choose File

Choose File

Pre Interview Questions

2. We all have Strengths and areas of opportunity for improvement . What would you say yours are?

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