Family Home Care Arizona and California's Quality In-Home Care Provider for Seniors and the Disabled

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IMPORTANT - PLEASE READ

Family Home Care, Inc., is an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, or physical or mental disability.

Use the Tab Button on your keyboard or point and click to move around in the form. Do not hit the Enter Button on your keyboard until you are completely finished. If you hit the the Enter Button it will end your session and send you to another page, the Form Confirmation page, that summarizes the information you have recorded. If you get to the Form Confirmation page and want to continue entering information, hit the Back Button and it will send you back to the Application and all the information you have entered will still be on the form. If you are finished completing the form, you can hit the Enter Button or the Submit Application Button at the end of the Application. It will end your session and send you to the Form Confirmation page. To submit the information, click on the "Return to the form" link on the bottom of the Form Confirmation page.

General Information

Social Security No. Date of On-Line Application

Last Name

First Name Middle Initial Date of Birth

Street Number & Apartment No.

City State Zip

Home Phone No.

Cellular Telephone No.

What is the position you are applying for?

Are you able to perform the essential functions of the position you are applying for? Yes No (Note: New Hires may be subject to passing a medical examination, and skill and agility tests)

Are you lawfully authorized to work in the U.S.? Yes No

Do you have reliable transportation to get to a work assignment on time? Yes No

Are you capable of reading, writing, and understanding English as part of performing job related duties? Yes No

Do you speak any languages other than English? Yes No If yes, please list:

Do you have access to a telephone and will you respond to job assignments in a timely manner?

Yes No

Do you have hands-on experience providing care services? Yes No

Please give us the name and telephone number of a contact person in the event we cannot get a hold of you:

Name: Number:

On what date are you available to start work?

What types of cases are you willing to work?:

Hourly Yes No

Shifts AM Yes No

Shifts PM Yes No

24 Hr Shifts Yes No

What days of the week and times of the day are you available to work?

Days and Hours Available Sat Sun Mon Tue Wed Thu Fri

Anytime Yes Yes Yes Yes Yes Yes Yes

From:

To:

What days of the week and times of the day are you not available to work?

PROFESSIONAL & TECHNICAL INFORMATION

Are you employed now? Yes No May we contact your present employer? Yes No

Are you licensed or certified in any capacity of health or home care? Yes No If Yes, the name of License or Certification:

Expiration Date:

Issuing State License/Certification Number

Has your license/certification ever been revoked or suspended? Yes No

If yes, state reason(s) for, date(s) of revocation or suspension, and date(s) of reinstatement.

Are you CPR certified? Yes No

Have you had a current TB Test? Yes No

Do you have the test results available? Yes No

Have you obtained a high school diploma or GED certificate? Yes No

School Name & Location Diploma/Degree Subject Of Specialization

College/University

Specialized Courses and Training

OTHER SPECIAL SKILLS - List Other Specific Skills You Have to Offer for This Job Opening:

Employment History - Begin with most recent employer.

     Most Recent Employer:

     Address:

     City:      State:      Zip:

     Phone No.:      Supervisors Name:

     Work Performed:     Job Title:

     Dates Employed From:     To:

     Starting Pay Rate:     Ending Pay Rate:

     Reason for Leaving:

     Next Most Recent Employer:

     Address:

     City:      State:      Zip:

     Phone No.:      Supervisors Name:

     Work Performed:     Job Title:

     Dates Employed From:     To:

     Starting Pay Rate:     Ending Pay Rate:

     Reason for Leaving:

     Next Most Recent Employer:

     Address:

     City:      State:      Zip:

     Phone No.:      Supervisors Name:

     Work Performed:     Job Title:

     Dates Employed From:     To:

     Starting Pay Rate:     Ending Pay Rate:

     Reason for Leaving:

Please Read Each Paragraph Carefully, Initial Each Paragraph,

and Electronically Sign Below

I hereby declare that I can perform the job-related functions applied for in this application. I further declare that the answers to the questions on this application are correct and that any misstatement of fact or omission could be cause for dismissal or rejection. I agree that any employment arrangement entered into is based upon the truthfulness of the statements that I have made herein. I understand I am a "Conditional Employee" until Family Home Care, Inc. has received verification of a satisfactory criminal background check and I have successfully obtained a Class II finger print card. Electronically Initial

I hereby agree to submit all disputes and claims arising out of the submission of this application to binding arbitration. I further agree, in the event that I am hired by Family Home Care, Inc., that all disputes that cannot be resolved by informal internal resolution arising out of my employment with Family Home Care, Inc. whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. Electronically Initial

I understand this is a preliminary application and not a contract to employ me. In the event I am employed by Family Home Care, Inc., I further understand that my employment is for no fixed time and may be discontinued with or without cause or notice by myself or the company. I understand that no Employee or officer or agent of Family Home Care, Inc. may bind it by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above. Electronically Initial

I UNDERSTAND THAT IF EMPLOYED, I WILL BE SUBJECT TO THE FOLLOWING AND DO VOLUNTARILY ACCEPT "AT WILL" EMPLOYMENT UNDER THESE CONDITIONS.

One or more of the following conditions constitutes a voluntary quit and unemployment benefits may be denied.

1. Failure to call or report for work WITHOUT NOTICE prior to absence. Electronically Initial

2. Failure to call or report for reassignment after an authorized absence. Electronically Initial

3. Failure to notify Family Home Care, Inc. of a change of address or phone number. Electronically Initial

4. Refusal or failure to accept suitable work assignments. Electronically Initial

I understand that if employed, if medication is prescribed by a doctor for me to take, and the medication prescribed may impair my performance of my job related duties, or endanger other workers, I am required to so notify management of the specific medical problem and the exact drug that has been prescribed, prior to working any job assignment. Electronically Initial

I understand that if employed, I will be required to maintain current CPR and First Aid certifications while employed by Family Home Care, Inc. and am responsible for the costs incurred thereof. In addition, I will be required to maintain current and furnish verification for a Fingerprint Card, TB Test results, personal automobile insurance (if driving any vehicle for a client of for FHC), and a current copy of my driving record. Electronically Initial

Employment Verification

I hereby authorize Family Home Care, Inc. (FHC) to seek references from previous employers listed on this form, and to obtain a report from a government-reporting agency to be used for employment purposes. I authorize the references and previous employers listed to give FHC all information and opinions concerning me and my previous employment. I release all such parties from any liability which may arise from furnishing such information to FHC including, but not limited to, any liability for defamation or invasion of privacy. A photocopy of this consent and release will be valid as an original even though the photocopy does not contain an original writing of my signature. I certify that I have read, fully understand and agree with the foregoing certification statement. This authorization will expire one year after the date signed and noted below.

By entering my name and today's date below and submitting this form, I am indicating that I am electronically signing this form and have read the above statements; I have correctly filled out the Application to the best of my knowledge; and understand the content, intent and terms of this Application.

Name: (First M.I. Last)                                                                          Date Today:
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Last Updated 12/15/2009