All prospective employees will receive consideration without discrimination because of race,
color, creed, age, natural origin or handicap. All information provided herein will be kept
confidential.
Have you ever applied for employment with this Agency? *
please indicate hours of availability below
Are you legally eligible for employment in the United States? *
How did you learn of our organization?
EDUCATION
High School
College
Vo-Tech or Trade
Employment
Are you currently employed? *
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care
and community support Agency? *
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in
full:
Are you capable of performing the job set forth in the job description? *
If you answered No, which job requirement can you not meet?
I certify that the facts contained in this application are true and complete to the best of my
knowledge and understand, that, if employed, falsified statements on this application SHALL BE
GROUNDS FOR DISMISSAL
I Authorize complete investigation of all statements contained herein anttd herby give my full
permission for the Agency to contact and fully discuss my background and history with all
persons and entities listed above to give the Agency any and all information concerning my
previous employment and any information they may have, and release all former employees and
others listed above from all liability for any damage that my result from furnishing the same I
to the Agency.
I understand and agree that, if hired, my employment is for no definite period and may,
regardless of the date of payment of my wages and salary, be terminated at any time for any
lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period of time not to exceed 45
days. Any applicant I wishing to be considered for employment beyond this time period shall
inquire as to whether or not applications are being accepted at that time.
Disclaimer: In exchange for the consideration of my job application by Senior Helpers, I agree
that: Neither the acceptance of this application nor the subsequent entry into any type of
employment relationship, either in the position applied for or any other position.f employment,
or to confer any right to remain an employee of Senior Helpers, or otherwise to change in any
respect the employment-at-will relationship between it and the undersigned, and that
relationship cannot be altered except by a written instrument signed by the President of Senior
Helpers. Both the undersigned and Senior Helpers may end the employment relationship at any
time, without specified notice or reason. I hereby release any and all prior employers or
current employers from liability or claims arising out of the provision of information about my
employment with such employer. I hereby waive any cause of action I might otherwise have against
such employer arising out of the provision of information concerning my employment. I also
understand that (1) Senior Helpers has a drug and alcohol policy that provides for
pre-employment testing as well as testing during employment; (2) consent to and compliance with
such policy is a condition of my employment; and (3) continued employment is based on the
successful passing of testing under such policy. I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE
TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this
application. I understand that the misrepresentation or omission of facts called for is cause
for dismissal at any time without any previous notice. I hereby give Senior Helpers permission
to contact schools, previous employers (unless otherwise indicated), references, and others, and
hereby release Senior Helpers from any liability as a result of such contact. Senior Helpers is
an equal employment opportunity employer. We adhere to a policy of making employment decisions
without regard to race, color, religion, sex, sexual orientation, national origin, citizenship,
age or disability. We assure you that your opportunity for employment with this depends solely
on your qualifications.
