Employment

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We'll Love To Have You On Our team

Complete the form below to apply and start your rewarding career at LivWell Home Care Agency LLC

Your Name

Address

Position applying forFull-timePart-timePRN

Are you legally eligible to work in the US?YesNo

Are you available to work Call Outs, if needed?YesNo

Have you ever been employed at LivWell Homecare Agency?YesNo

Do you have any friends or family employed at this location? YesNo

FYI: Conviction will not be a deciding factor in continuing the pre-screening process or potential employment opportunities.

Have you been convicted of a crime in the last seven (7) years?YesNo

During the hiring process, do you agree to provide a criminal background check?YesNo

During the hiring process, do you agree to provide a Motor Vehicle Record?YesNoN.A.

Educational Background: Please Answer The Following Questions.

List previous educational history

Graduated?YesNo

Documents Checklist

Documents	Current	Expires
CNA Certification	YesNo
CPR First Aid	YesNo
Driver's License	YesNo
TB Screening	YesNo

Please answer the following Questions.

EMPLOYMENT BACKGROUND. List your previous employers beginning with the most recent employer.

Employer 1

Employer Name
Phone
Address
Job Title
Employment Duration
Responsibilities
Supervisor Name
Supervisor Phone
May we call to verify?	YesNoLater
Starting Hourly Rate
Final Hourly Rate
Reason for leaving

Employer 2

Employer Name
Phone
Address
Job Title
Employment Duration
Responsibilities
Supervisor Name
Supervisor Phone
May we call to verify?	YesNoLater
Starting Hourly Rate
Final Hourly Rate
Reason for leaving

Employer 3

Employer Name
Phone
Address
Job Title
Employment Duration
Responsibilities
Supervisor Name
Supervisor Phone
May we call to verify?	YesNoLater
Starting Hourly Rate
Final Hourly Rate
Reason for leaving

References: List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

Reference 1

Name
Relationship
Years acquainted
Phone Number

Reference 2

Name
Relationship
Years acquainted
Phone Number

Reference 3

Name
Relationship
Years acquainted
Phone Number

Certify

**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 the company and/or its agents, including consumers 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 background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. 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.

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, national origin, ancestry, veteran status, medical condition, sexual orientation, marital status or any other characteristic protected by applicable state or federal civil rights laws.

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