EMPLOYMENT APPLICATION

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sexual orientation, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

PERSONAL INFORMATION

Position(s) Applying For:	ABI CAREGIVER?	ELDERCARE CAREGIVER?		OTHER?		Today’s Date
Name:	Last		First		Middle
Current Address	Street/Apt	City		State		Zip Code
(*If you’ve lived at current address for less than 3yrs, provide a previous address below)
Previous Address	Street/Apt	City		State		Zip Code
(*If you’ve lived at current address for less than 3yrs, provide a previous address below)
Social Security #:			Home Phone:
Cell Phone:			Work Phone:
Email Address:
Emergency Contact(s):	Name			Phone
	Name			Phone
Valid Driver’s License #:		State Issued:		Exp. Date:
Auto In Co:		Policy #		Exp. Date:

Have you ever submitted an application here before? YES NO If yes, when?

Have you ever been employed here before? YES NO If yes, when?

How did you hear about Connecticut Community Focus, LLC?

Are you able to perform the essential functions of the job for the which you are applying with or without a reasonable

accommodation?

Yes
No

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hoursworked.

What date are you available to begin work?

Please complete all areas of availability:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
From:
To:

REFERENCES

Are you willing to provide service to a client with a pet? Yes No If yes, which ones:

Cats

Dogs

Are you willing to provide service to a client that smokes?

Yes No

JOB RELATED SKILLS

Describe any duties and experience you have in providing Personal Care:

Describe your duties as a Homemaker:

Describe your duties as a Companion:

EDUCATION

*For employment our minimum education requirement is either a GED or High School diploma

Please write highest grade completed:

School Type	School Name	City, State	Major/Subject	# Yrs Attended	Graduate
High School					YesNo
Vocational/Technical					YesNo
College/University					YesNo

OTHERSKILLS/QUALIFICATIONS/CERTIFICATIONS:

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort
to contact previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER

Are you currently working for this employer? YES NO If yes, may we contact? YES NO

Company Name		City		State		Phone Number
Dates Employed:	From		to		Job Title		Supervisor's Name
Starting Hourly Rate of Pay				Ending Hourly Rate of Pay
Duties
*Reason for Leaving*

SECOND MOST RECENT EMPLOYER

Company Name		City		State		Phone Number
Dates Employed:	From		to		Job Title		Supervisor's Name
Starting Hourly Rate of Pay				Ending Hourly Rate of Pay
Duties
*Reason for Leaving*

THIRD MOST RECENT EMPLOYER

Company Name		City		State		Phone Number
Dates Employed:	From		to		Job Title		Supervisor's Name
Starting Hourly Rate of Pay				Ending Hourly Rate of Pay
Duties
*Reason for Leaving*

SECURITY

*******Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.
As a condition of employment all employees must be “Bondable”& “Insurable”. Are you at least 19 years of age? YES NO

List states and counties of residence for the past seven years:

Have you had any moving traffic violations? YES NO If yes, please describe:

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? YES NO

Have you been charged/convicted of a felony and/or misdemeanor/or served time YES NO If yes, please describe:

Incident

City/State

Charge

Have you been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction? YES NO If yes, please describe:

Incident

City/State

Charge

REFERENCES

(Do not include relatives. Supervisory references preferred)Please complete at least 3 references.
Since we will contact these references, please notify them in advance. If we are unable to reach them, you will be asked for additional references.

Full Name	Phone Number	Best Time of Day to Call
1)	H( ) W( )	AMPM AMPM
2)	H( ): W( )	AMPM AMPM
3)	H( )	AMPM AMPM

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one (1) 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 misrepresentations of facts 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 consumer-reporting bureaus, to verify any of this 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 release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Connecticut Community Focus, LLC, and myself is terminable at-will, so that both the company and I remain free to choose to end our work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed. "I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law."

APPLICANT SIGNATURE:

Date:

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

AVAILABILITY

REFERENCES

JOB RELATED SKILLS

EDUCATION

WORK HISTORY

MOST RECENT EMPLOYER

SECOND MOST RECENT EMPLOYER

THIRD MOST RECENT EMPLOYER

SECURITY

REFERENCES

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Services

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