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Employment Application

First Name:
Last Name:
Street Address:
City:
State:
Zip:
Phone Number:
Cell Number:
Email Address:
Are You Eligible To Work In The United States? Yes | No
If you are under age 18, do you have an employment/age certificate? Yes | No
Have you been convicted of or pleaded no contest to a felony? Yes | No
If yes, please explain:
Would you agree to a criminal background check? Yes | No
Do you have a reliable car and valid Driver’s License? Yes | No
What distance would you be willing to travel to clients?



AVAILABILITY:

Please indicate your Days/Hours Available (Minimum of 15 hours per week for Part-Time Employment)
Monday Times:
Tuesday Times:
Wednesday Times:
Thursday Times:
Friday Times:
Saturday Times:
Sunday Times:
What date are you available to start work?
Are you be available to work holidays? (time and half pay)
Are you aware of any scheduled vacations or time off needed?



EDUCATION:

Are you a High School Graduate?
Yes | No
Name and Address of School/College
Degree/Diploma
Graduation Date

SKILLS and QUALIFICATIONS: Licenses, Skills, Training, Awards:



EMPLOYMENT HISTORY:

Present Or Last Position:
Employer:
Address:
Supervisor:
Phone:
Email Address:
Position Title:
From: To:
Responsibilities:
Reason for Termination or Leave:
May We Contact Your Present Employer? Yes | No



REFERENCES:

Name/Title Address Phone:
Name/Title Address Phone:
Do you have any caregiver experience working with seniors or other populations?
When referring to our website, are there any service listed that you would not feel comfortable providing?  (And Why?)
What personal qualities do you feel would benefit those you come in contact with through M&T HelpingHands?
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature: Check Box To Sign
 

 

518-380-9788

 

Helping Hands@Home is the preferred provider for the
The Eddy Health Alert Medical systems. 

 

Helping Hands @ Home, LLC

Copyright 2014 by Helping Hands @ Home, LLC
125 Adams Street, Delmar NY 12054
518-380-9788

Senior Home Caregiver Services available in all of the Capital District including Albany, Bethlehem, Clifton Park, Colonie, East Greenbush, Latham, Loudonville, and Niskayuna

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