Date: 7/28/2015

Application Form

Worcester Home Care

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.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License Number
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1. Date available:  
     
2. Interested in per diem work:  
     
3. All employees must be willing to work two Sundays a month for at least 4-8hrs. Are you willing to do so? If not, you will not be considered.  
     
4. Hours available Sundays (Please be specific - Example 7A-3P):  
     
5. Hours available Mondays (Please be specific - Example: 7A-3P):  
     
6. Hours available Tuesdays (Please be specific - Example 7A-3P):  
     
7. Hours available Wednesdays (Please be specific - Example: 7A-3P):  
     
8. Hours available Thursdays (Please be specific - Example 7A-3P):  
     
9. Hours available Fridays (Please be specific - Example 7A-3P):  
     
10. Hours available Saturdays (Please be specific - Example: 7A-3P):  
     

Section 2 - Employment Eligibility/Background Check Info:

Number Question Effective Date Expiration Date
1. Are you a U.S. citizen?:  
     
2. If you are not a U.S. citizen, VISA number (required):  
     
3. Are you authorized to work in the U.S.?  
 
 
 
 
4. Country of origin:  
     
5. Birthdate:  
     
6. Sex:  
 
 
7. Forms of ID:  
 
 
 
 
 
8. Driver's License Number:  
     

Section 3 - Education

Number Question Effective Date Expiration Date
1. Certifications:  
 
 
 
 
 
2. Is your certification current?:  
     
3. School of certification:  
     

Section 4 - Current Employment

Number Question Effective Date Expiration Date
1. Current Employer:  
     
2. Date Hired:  
     
3. City and State:  
     
4. Phone (XXX-XXX-XXXX):  
     
5. Hours Worked:  
 
 
 
 
6. Position/Title:  
     
7. Describe responsibilities:  
 
8. Supervisor's name:  
     
9. Supervisor's title:  
     
10. Supervisor's phone (XXX-XXX-XXXX):  
     
11. Reason for looking for other work:  
 
12. May we contact?:  
     

Section 5 - Employment History

Number Question Effective Date Expiration Date
1. Last Employer:  
     
2. Approximate dates employed:  
     
3. City and State:  
     
4. Phone (XXX-XXX-XXXX):  
     
5. Position/Title:  
     
6. Describe responsibilities:  
 
7. Supervisor's name:  
     
8. Supervisor's title:  
     
9. Supervisor's phone (XXX-XXX-XXXX):  
     
10. Reason for leaving:  
 
11. May we contact?:  
     

Section 6 - Employment History 2

Number Question Effective Date Expiration Date
1 Former Employer:  
     
2. Approximate dates employed:  
     
3. City and State:  
     
4. Phone (XXX-XXX-XXXX):  
     
5. Position/Title:  
     
6. Describe reponsibilities:  
 
7. Supervisor's name:  
     
8. Supervisor's title:  
     
9. Supervisor's phone (XXX-XXX-XXXX):  
     
10. Reason for leaving:  
 
11. May we contact?:  
     

Section 7 - Reference 1 (Directly related to personal care)

Number Question Effective Date Expiration Date
1. Name:  
     
2. Company:  
     
3. Title:  
     
4. Relation:  
     
5. Phone:  
     

Section 8 - Reference 2 (Directly related to personal care)

Number Question Effective Date Expiration Date
1. Name:  
     
2. Company:  
     
3. Title:  
     
4. Relation:  
     
5. Phone:  
     

Section 9 - Reference 3

Number Question Effective Date Expiration Date
1. Name:  
     
2. Company:  
     
3. Title:  
     
4. Relation:  
     
5. Phone:  
     

Section 10 - Reference 4

Number Question Effective Date Expiration Date
1. Name:  
     
2. Company:  
     
3. Title:  
     
4. Relation:  
     
5. Phone:  
     

Section 11 - Source

Number Question Effective Date Expiration Date
1 How did you hear about us?  
 
 
 
 
2 How did you hear about us? (cont.)  
     

Section 12 - Disclaimer 1

Number Question Effective Date Expiration Date
1 I certify that this application is true and complete. I understand false information may be grounds for not hiring me or for immediate termination in the future if hired. I authorize the verification of all information listed above. (required)  
     
2 With submission, applicant recognizes employment as PER DIEM, with NO expectation of a regular schedule. Employee might not receive unemployment benefits generally assigned to full-time or salaried employees. (required)  
     
3 With submission, applicant recognizes employment as AT WILL. Employee would be subject to termination based solely on Company discretion. (required)  
     
4 I agree to be available to work at least two Sundays every month for 4-8 hours each day and to accept such appointments when offered. I understand that not being available for these Sunday hours changes our employment agreement at the time of hiring. Employees who become unavailable for this Sunday requirement become subject to termination without expectation of benefits. I also understand this does not guarantee that hours will be offered on Sundays. Details are in the employee service agreement and employee handbook. (required)  
     



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.