Full Time President Ceo

A Better Solution In Home Care

www.absihc.com

EMPLOYMENT APPLICATION

PERSONAL DATA

Legal Name (Last) (First, MI) Position Applied For: Address (List all addresses from past seven (7) years – Use back of form if necessary. Current Address - Street City State Zip Code Years at Address Previous Address – Street City State Zip Code Years at Address Home Telephone No. Current Work Telephone No. Cellular Telephone No. Email Address: Can you produce evidence of the right to work while in the U.S.? Yes No

Are you at least 18 years of age? Yes No

What type of work are you interested in?

Full Time Part Time Per Diem

Date you will be available for work? Have you ever held a position with ABS? Yes No If Yes, what position?

EDUCATION

School Name

(City, State Required)

Major/Minor Graduate Type of Degree Grade Point

Average

Yes

No

GED

Yes

No

Yes

No

EMPLOYMENT List all employment during the past 5 years. If you need more space, use additional paper.

(1) Employer’s Name

Street Address City State Zip Code

Job Title Supervisor’s Name/Title Supervisor’s Telephone No. Dates of Employment (mm/yy) From: / to /

Reason for Leaving: Duties:

(2) Employer’s Name Street Address City State Zip Code Job Title Supervisor’s Name/Title Supervisor’s Telephone No. Dates of Employment (mm/yy) From: / to /

Reason for Leaving: Duties:

(3) Employer’s Name Street Address City State Zip Code Job Title Supervisor’s Name/Title Supervisor’s Telephone No. Dates of Employment (mm/yy) From: / to /

Reason for Leaving: Duties:

COMPUTER SKILLS

Typing

wpm

Software programs which you have experience with (if applicable): LANGUAGES

Language #1 Speak

Read

Write

Language #2 Speak

Read

Write

Language #3 Speak

Read

Write

BACKGROUND INFORMATION

When completing this section, do not disclose information regarding convictions that have been judicially erased, sealed, expunged, eradicated, impounded or dismissed. Do not disclose information regarding juvenile court convictions or minor traffic violations. A conviction record does not automatically bar you from employment. 1. In the past seven (7) years, have you been convicted of any felony? Yes No 2. In the past seven (7) years, have you been convicted of any misdemeanor? Yes No 3. If you answered "Yes” to either of the questions above, please explain completely: BUSINESS REFERENCES

Name Job Title Address Telephone Number

PLEASE INDICATE YOUR SCHEDULE AVAILABILITY, TRAVEL AVAILABILITY AND SKILLS Please check DAYS

available

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Comments:

Please check SHIFTS

available

Morning

Afternoon

PM

Night

1-2 hours

2-4 hours

4 –8 hrs.

8-12 hrs.

Other:

Number of WEEKENDS available to work per month

Which holidays are you available to

work?

New Year’s Day

Memorial Day

Independence Day

Labor Day

Thanksgiving Day

Christmas Day

How many MILES are you willing to drive to and from work? Comments: CLIENTS YOU ARE NOT WILLING/ABLE TO WORK WITH

Dementia/Alzheimer’s Smokers

Mental Retardation Pets (Specify): Cats Dogs Other:

Behavioral Disorders Females

Elderly (over 65) Males

HIV Positive/AIDS Client use of medically prescribed marijuana

Other (Specify):

TRANSPORTATION

What type of transportation do you use? Car Bus Bike Other: Do you have a valid Driver License? Yes No DL#: Expiration Date: Are you willing to transport clients in your private vehicle? Yes No Are you willing to drive a client’s vehicle? Yes No Do you have auto insurance? Yes No Are you willing to escort a client on public transportation? Yes No Are you willing to escort a client in their own vehicle? Yes No Comments: www.absihc.com

AUTHORIZATION AND UNDERSTANDING

RELEASE OF PRIOR PERSONNEL

INFORMATION

By signing this application, I agree that all of the information now or later given by me in support of my application for employment is true and complete. I understand that A Better Solution may verify any of the information concerning my employment, education and/or criminal history with the appropriate individuals, organizations or governmental agencies. I give these individuals, organizations or governmental agencies my permission to release any information that is needed, including my previous disciplinary record, without requiring them to contact me or give me a written notice before revealing the information to A Better Solution. I agree that any false information in support of my application may subject me to discharge at any time during my employment. AT-WILL EMPLOYMENT STATUS

I AGREE THAT EITHER PARTY MAY TERMINATE THE EMPLOYMENT RELATIONSHIP, WITH OR WITHOUT CAUSE, AT ANY TIME, FOR ANY REASON, AND I FURTHER AGREE THAT THIS AGREEMENT MAY ONLY BE CHANGED BY THE PRESIDENT/CEO OF THE COMPANY, IN WRITING, DIRECTED TO ME PERSONALLY, AND SIGNED BY THE PRESIDENT/CEO. I agree that I shall be bound by the other rules, regulations, and terms and conditions of employment of the company as they are from time to time changed and that no additional obligations can be imposed by me on the company except those which have been acknowledged, in writing, by the company CEO/President or his/her designated representative. I further agree that my employment is conditional upon satisfactory completion of documentation as required by the Immigration Reform and Control Act of 1986 and until such time as the result of my pre-employment physical (if such physical is required) is known. RELEASE FOR REFERENCE

CHECKS

I authorize A Better Solution to contact my previous employers for work-related references. RELEASE FOR BACKGROUND SCREENING

I authorize A Better Solution to verify any information that I provide in connection with my employment. I release A Better Solution and its authorized representatives of all liability resulting from the use of background information about me for employment purposes.

Applicant’s Signature Date

Contact this candidate