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Phone Number
708-879-2840
Fax Number
708-365-2949
Email Address
Info@a1-homecareservices.com
920 175th Suite 6,
Homewood, IL 60430
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708-879-2840
708-365-2949
info@a1-homecareservices.com
Instagram
Home
About Us
Our Services
Client Care Overview
Hourly Home Care
Daily Home Care
Hospital to Home Care
Specialized Care
Caregivers
Careers
Menu
Home
About Us
Our Services
Client Care Overview
Hourly Home Care
Daily Home Care
Hospital to Home Care
Specialized Care
Caregivers
Careers
Contact Us
708-879-2840
708-365-2949
info@a1-homecareservices.com
920 175th Suite 6, Homewood, IL 60430
Contact Us
Application for Employment
Name
First
Middle
Last
Date
MM slash DD slash YYYY
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Telephone
Cell Phone
E-Mail address
Referred to us by
Position(s) applied for
Homemaker
Caregiver
CNA
Other
Date available
MM slash DD slash YYYY
Type of employment desired
Full-Time
Part-Time
On-Call
Live-In Shift
Please Specify Days and Hours you are available:
If currently employed, may we contact your employer?
Yes
No
Rate of Pay Expected $
Is there a specific reason you are applying for employment at this company?
Yes
No
If Yes, please briefly outline the reason:
Are you legally eligible for employment in this country?
Yes
No
Are you available to work overtime if required?
Yes
No
Have you applied with this company before?
Yes
No
o you have any friends or family employed at this location?
Yes
No
Have you been convicted of a crime in the last seven (7) years?
Yes
No
If yes, please explain
If considered for hiring, will you agree to provide a criminal background check?
Yes
No
If considered for hiring, will you agree to provide a driver’s motor vehicle check?
Yes
No
EDUCATIONAL BACKGROUND
List previous three (3) educational institutions attended, beginning with the most recent.
School
CITY, STATE/PROVINCE
GRADUATED?
Yes
No
DEGREE(s)/DIPLOMA(s) EARNED
School
CITY, STATE/PROVINCE
GRADUATED?
Yes
No
DEGREE(s)/DIPLOMA(s) EARNED
School
CITY, STATE/PROVINCE
GRADUATED?
Yes
No
DEGREE(s)/DIPLOMA(s) EARNED
What licenses, registrations or relevant designations if any, do you possess?
Type
Date of Most Recent Registration
MM slash DD slash YYYY
Valid in State of Illinois
Yes
No
Type
Date of Most Recent Registration
MM slash DD slash YYYY
Valid in State of Illinois
Yes
No
CNA /Home Aide
Yes
No
Last Certified
CPR / First Aid
Yes
No
Last Certified
TB
Yes
No
Last Certified
Please indicate other licenses and certifications
EMPLOYMENT BACKGROUND
Provide the following information beginning with the most recent employer.
EMPLOYER
TELEPHONE
DATES EMPLOYED (FROM)
MM slash DD slash YYYY
DATES EMPLOYED (TO)
MM slash DD slash YYYY
ADDRESS
JOB TITLE
HOURLY RATE/SALARY (Starting)
HOURLY RATE/SALARY (Final)
IMMEDIATE SUPERVISOR AND TITLE AND PHONE NUMBER
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
EMPLOYER
TELEPHONE
DATES EMPLOYED (FROM)
MM slash DD slash YYYY
DATES EMPLOYED (TO)
MM slash DD slash YYYY
ADDRESS
JOB TITLE
HOURLY RATE/SALARY (Starting)
HOURLY RATE/SALARY (Final)
IMMEDIATE SUPERVISOR AND TITLE AND PHONE NUMBER
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
EMPLOYER
TELEPHONE
DATES EMPLOYED (FROM)
MM slash DD slash YYYY
DATES EMPLOYED (TO)
MM slash DD slash YYYY
ADDRESS
JOB TITLE
HOURLY RATE/SALARY (Starting)
HOURLY RATE/SALARY (Final)
IMMEDIATE SUPERVISOR AND TITLE AND PHONE NUMBER
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
EMPLOYER
TELEPHONE
DATES EMPLOYED (FROM)
MM slash DD slash YYYY
DATES EMPLOYED (TO)
MM slash DD slash YYYY
ADDRESS
JOB TITLE
HOURLY RATE/SALARY (Starting)
HOURLY RATE/SALARY (Final)
IMMEDIATE SUPERVISOR AND TITLE AND PHONE NUMBER
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE?
Yes
No
Later
REFERENCES
List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).
NAME
RELATIONSHIP
YEARS ACQUAINTED
Phone Number
NAME
RELATIONSHIP
YEARS ACQUAINTED
Phone Number
NAME
RELATIONSHIP
YEARS ACQUAINTED
Phone Number
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.
Applicant’s Signature
Date
MM slash DD slash YYYY