Employment Form

Thank you for applying for employment with Careplus. Like many employers, Careplus requires that you complete an application in order to be eligible for employment. Please answer all questions on this application.

Careplus Home Health Services is an equal opportunity employer. Careplus considers applicants for all positions without discrimination on the basis of race, color, religion, sex, national origin, age, disability, marital status or veteran status, or any other legally protected status. No question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on any basis prohibited by local, state, or federal law.

* = Required Information

Today's Date

Last Name *

First Name *

Middle Name

DOB *

SSN #

Street Address

Apt

City

Zip *

State

Email W: *

Email H:

Emergency Contact:

Emergency Phone:

PHONE

Phone Day *

Phone Evening

Cell:

Other:

Only U.S. citizens or other persons who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, submit documentation verifying your identity and legal right to work in the U.S.?

Yes

No

Have you ever been convicted or pled no contest to a felony?

Yes

No

If so, state the nature of the offense(s), date(s), city, state and disposition. A conviction or plea record will not necessarily disqualify an applicant from employment.

CURRENT/MOST RECENT EMPLOYMENT

Company:

Position:

From:

To

Primary Responsibilities:

Salary:

Bonus Y N

Reason for Leaving?

EDUCATION

High School

Print Name, City and State for each School

Did you Graduate?

Yes

No

Yr. Of Grad

Major and Degree

College

Print Name, City and State for each School

Did you Graduate?

Yes

No

Yr. Of Grad

Major and Degree

Graduate School

Print Name, City and State for each School

Did you Graduate?

Yes

No

Yr. Of Grad

Major and Degree

Certifications

Print Name, City and State for each School

Did you Graduate?

Yes

No

Yr. Of Grad

Major and Degree

Other

Print Name, City and State for each School

Did you Graduate?

Yes

No

Yr. Of Grad

Major and Degree

PLEASE PROVIDE THE NAMES OF AT LEAST THREE BUSINESS REFERENCES:

Name:

Company:

Relationship:

Email:

Phone #:

Employment Application Certification

I hereby certify that all of the facts and information listed on this employment application are true and complete. I understand that any false, incomplete or misleading information given by me on this application is sufficient cause for rejection of this application. I also understand and agree that any such false, incomplete, or misleading information discovered on this application at any time after I am employed may result in my dismissal..

I hereby authorize the Company to investigate all statements contained in this application and to interview the references and previous employers listed in this application or identified by me. I authorize the references and previous employers listed to give the Company all facts, opinions and evaluations concerning my previous employment and any other information they may have, personal or otherwise, and release all such parties from any liability which may allegedly arise from furnishing such information to the Company, including, but not limited to, any liability for defamation or invasion of privacy.

I acknowledge that the Company has advised me that a Degree / Certification check may be performed, that will inquire into information about my education and/or certificates. This will serve as my authorization for you to perform an investigation and further authorizes the Institutions / University to release to the Company my personal data.

If I am offered employment, I understand that such an offer may be conditioned upon satisfactory results of a background investigation and/or Company medical examination or inquiry, including a drug screen test, in some circumstances. This may also include personal credit history and reports, criminal and civil records, drivers license and identification verifications. If then employed, I understand that I will be required to serve a ninety (90) day introductory period. I further understand that my employment and compensation can be terminated, with or without cause or notice, at any time, regardless of the successful completion of my introductory period, at the option of either the Company or myself. I understand that no supervisor or other representative of the Company other than the President of the Company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

I further understand and voluntarily agree as a condition of employment or my continued employment, that I may be requested by the Company to submit to a urine analysis or other drug screen test and that my failure to take such test(s) when requested to do so or unsatisfactory test results will disqualify me from consideration for employment, or if I am then employed, may result in my immediate dismissal.

I agree that any controversy or dispute arising between me and the Company with respect to this application, the Company's consideration of my employment, my employment by the Company, or the termination of my employment by the Company shall be submitted for arbitration pursuant to the Company's rules and procedures for arbitration.

I certify that I have read, understand and agree to the above.

Date

Signature of Applicant

Security code