Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Office Location

Personal Information

Section 1 - Date

Section 2 - Emergency Contact

Section 3 - Transportation-Driving is required for hourly work

Section 4 - Availabilty

(Numeric Answer Only)

Section 5 - Education

Section 6 - Experience

Section 7 - Skills

Section 8 - Employment History

Section 9 - Work references

Section 10 - References-Personnal

Section 11 - Certifications

Section 12 - Malpractice Insurance

Section 13 - Information Release Authoriztion

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize Affordable Senior Home Care and or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my backround and hearby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.