Phone Number

708-879-2840

Fax Number

708-365-2949

Email Address

Info@a1-homecareservices.com

920 175th Suite 6,

Homewood, IL 60430

Application for Employment

Name
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Address

Position(s) applied for
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Type of employment desired
If currently employed, may we contact your employer?
Is there a specific reason you are applying for employment at this company?
Are you legally eligible for employment in this country?
Are you available to work overtime if required?
Have you applied with this company before?
o you have any friends or family employed at this location?
Have you been convicted of a crime in the last seven (7) years?
If considered for hiring, will you agree to provide a criminal background check?
If considered for hiring, will you agree to provide a driver’s motor vehicle check?

EDUCATIONAL BACKGROUND

List previous three (3) educational institutions attended, beginning with the most recent.
GRADUATED?
GRADUATED?
GRADUATED?

What licenses, registrations or relevant designations if any, do you possess?
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Valid in State of Illinois
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Valid in State of Illinois
CNA /Home Aide
CPR / First Aid
TB

EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.
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MAY WE CONTACT FOR REFERENCE?
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MAY WE CONTACT FOR REFERENCE?
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MAY WE CONTACT FOR REFERENCE?
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MAY WE CONTACT FOR REFERENCE?

REFERENCES

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

I certify that all the information I have provided is true, complete, and correct.

The information contained within this application, or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.

I authorize the employer to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal

I understand that if I am hired, I will be required to provide criminal background check, proof of identity and legal authority to work in Illinois, proof of certifications or educational qualifications, and a driver abstract (if applicable).

Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.
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