Employment Application

An equal opportunity employer, A1care does not discriminate in hiring or terms and conditions of employment because of an individual’s age (40 and older), ancestry, color, religious creed (including religious dress and grooming practices), denial of family and medical care leave, disability (mental and physical) including HIV and AIDS, marital status, medical condition (cancer and genetic characteristics), genetic information, military and veteran status, national origin (including language use restrictions), race, sex (which includes pregnancy, childbirth, breastfeeding and medical conditions related to pregnancy, childbirth and breastfeeding), gender, gender identity, gender expression and sexual orientation or any other basis protected by federal, state, or local law, ordinance or regulation.

Step 1 of 8

Personal Information
Name*
First Middle Last
Home Care Aide/PER ID #*
Required. See here for details.
Are you authorized for employment in the U.S?*
- Yes
- No
Present Street Address*
Street Address Address Line 2 City State ZIP Code
How long have you lived there?*
Previous Street Address*
Street Address Address Line 2 City State ZIP Code
How long did you live there?*
Phone Number*
Social Security Number*
Email Address*
Date of Birth*
Month
Day
Year

Additional Information
Is there any additional information involving a change of name or assumed name that will permit us to check your work record?*
Have you ever been employed by A1care before?
- Yes
- No
Employment dates*
Location(s)*
Position held*
Have you ever been convicted of a crime other than a traffic violation?*
- Yes
- No
NOTE: Exclude misdemeanor convictions for marijuana-related offenses more than two years old; convictions that have been sealed, expunged, or legally eradicated; and misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially dismissed. A conviction is not an automatic bar to employment. Each case will be considered on its own merits.
Please explain and state the charge, the court, the date of conviction, and the disposition of the case:*
List names of friends or relatives now or formerly employed by A1care.
Emergency Contact
Name*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code

Employment History
List employment starting with your most recent position. Account for any time during this period that you were unemployed by stating the nature of your activities.
May we contact your current employer?*
- Yes
- No
Date From:
MM slash DD slash YYYY
Date To:
MM slash DD slash YYYY
Name of employer
Address of emploer
Street Address Address Line 2 City State ZIP Code
Phone
Job title
Supervisor
Starting Wages
Final Wages
Reason for leaving
Work Performed
Date From:
MM slash DD slash YYYY
Date To:
MM slash DD slash YYYY
Name of employer
Address of employer
Street Address Address Line 2 City State ZIP Code
Phone
Job title
Supervisor
Starting Wages
Final Wages
Reasons for leaving
Work Performed
Date From:
MM slash DD slash YYYY
Date To:
MM slash DD slash YYYY
Name of employer
Address of employer
Street Address Address Line 2 City State ZIP Code
Phone
Job Title
Supervisor
Starting Wages
Final Wages
Reasons for leaving
Work Performed
Date From:
MM slash DD slash YYYY
Date To:
MM slash DD slash YYYY
Name of employer
Address of employer
Street Address Address Line 2 City State ZIP Code
Phone
Job title
Supervisor
Starting Wages
Final Wages
Reasons for leaving
Work Performed

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Employment Application

Step 1 of 8

Personal Information

Education

Additional Information

Emergency Contact

Availability

Employment History

Special Skills and Qualifications

PLEASE READ THIS STATEMENT CAREFULLY

Caregiver Qualifications

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