BACKGROUND INQUIRY
I understand that an investigative background inquiry is to be made on myself including, but not limited to, consumer credit history, criminal history, driving history, education and other reports. These reports may include information as to my character, work habits, job performance, and experience, along with reasons for termination of past employment. I further understand that information will be requested from various federal, state, and other agencies which may maintain records concerning my past activities relating to my driving, credit performance, criminal conduct, civil court, and other experiences.
I authorize, without reservation, any party or agency contacted to furnish the information below.
I hereby consent to you obtaining the information below. I further understand that to aid in the proper identification of my file or records, I am providing the following information, as well as any other information that may be required at a later date. If hired, I understand that background inquiries will be performed every month.
HAVE YOU EVER BEEN CONVICTED OF A CRIME?YesNo
In what state and year?
APPLICANT INFORMATION
First Name:
Middle Name:
Last Name:
Date of Birth:
Home Phone:
Cell Phone:
MaleFemale
Email address:
Ethnic Group:CaucasianAfrican AmericanAsian/Pacific IslanderHispanicNative American/Alaska NativeOther
Please specify:
What other languages do you speak?
Position applied for:
Date available:
Desired salary:
Do you have any allergies? YesNo
What kind?
Do you have reliable transportation? YesNo
Do you own a car? YesNo
Do you know how to use the hoyer lift? YesNo
Are you a citizen of the United States?YesNo
If no, are you authorized to work in the U.S.?YesNo
Have you ever worked for Companions and Home Helpers?YesNo
If yes, when?
Have you ever been convicted of a felony?YesNo
If yes, explain:
Current Address:
How long at address?
City:
State: —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code:
Previous Address:
EDUCATION
Last School/College Attended:
State: —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Last Year Attended:
Graduated? YesNo Registered and/or graduated under what name?
If you graduated, indicate: CertificateGEDDiplomaDegree
Degree Level/Major:
High School:
Address:
From:
To:
Did you graduate?YesNo Degree:
College:
Other:
EMPLOYMENT HISTORY
Company/Client:
Supervisor:
Phone:
Job Title:
From: To:
Job Responsibilities:
Reason for Leaving:
May we contact your previous supervisor for a reference?YesNo
PROFESSIONAL REFERENCES
Full Name:
Relationship:
Company:
City: State: —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code:
EMERGENCY CONTACT
Name:
MILITARY SERVICE
Rank at Discharge:
Type of Discharge:
If other than honorable, please explain:
I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law. (Regulation Section 20-670-2(a))
Attach Resume:
Attach Cover Letter:(if applicable)
Attach CNA/PCA/HHA certification:(if applicable)
Applicant's Signature:
By typing my name below I certify that the statements made on this application are true and complete to the best of my knowledge, and are made in good faith.
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