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Online Application

Important – Please read before completing the application

Family Home Care, Inc., is an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, or physical or mental disability.


Personal Information

Application Date

First Name Middle Last Name

Date of Birth

Street Address

City State Zipcode

Home Phone Cell Phone

Please give us the name and telephone number of a contact person in the event we cannot get a hold of you:
Name: Phone Number:


General Employment Information

What position are you applying for?

Are you able to perform the essential functions of the position you are applying for?  yes no
(Note: New Hires may be subject to passing a medical examination, and skill and agility tests)

Are you lawfully authorized to work in the U.S.?  yes no

Do you have reliable transportation to get to a work assignment on time?  yes no

Are you capable of reading, writing, and understanding English as part of performing job related duties?  yes no

Do you speak any languages other than English?  yes no
If "Yes" please list:

Do you have access to a telephone and will you respond to job assignments in a timely manner?  yes no

Do you have hands-on experience providing care services?  yes no

On what date are you available to start work?

What types of cases are you willing to work?
Hourly  yes no
Shifts AM  yes no
Shifts PM  yes no
24 Hour Shifts  yes no

What days of the week and times of the day are you available to work?
Day and hour availability

Saturday
Anytime  yes
From:  am  pm
To:  am  pm

Sunday
Anytime  yes
From:  am  pm
To:  am  pm

Monday
Anytime  yes
From:  am  pm
To:  am  pm


Tuesday
Anytime  yes
From:  am  pm
To:  am  pm

Wednesday
Anytime  yes
From:  am  pm
To:  am  pm

Thursday
Anytime  yes
From:  am  pm
To:  am  pm


Friday
Anytime  yes
From:  am  pm
To:  am  pm

What days of the week and times of the day are you not available to work?


Professional and Technical Information

Are you employed now?  yes no

May we contact your present employer?  yes no

Are you licensed or certified in any capacity of health or home care?  yes no
If Yes, the name of License or Certification: Expiration date:
Issuing state License/Certification number

Has your license/certification ever been revoked or suspended?  yes no
If yes, state reason(s) for, date(s) of revocation or suspension, and date(s) of reinstatement.

Are you CPR certified?  yes no

Have you had a current TB Test?  yes no

Do you have the test results available?  yes no

Have you obtained a high school diploma or GED certificate?  yes no

School Name & Location Diploma/Degree Subject Of Specialization

College/University

Specialized Courses and Training

Other Special Skills - List Other Specific Skills You Have to Offer for This Job Opening:


Employment History

Begin with most recent employer.

Most Recent Employer:

Street Address

City State Zipcode

Phone No.: Supervisors Name:

Work Performed: Job Title:

Date Employed From: To:

Starting Pay Rate: Ending Pay Rate:

Reason for Leaving:


Next Recent Employer:

Street Address

City State Zipcode

Phone No.: Supervisors Name:

Work Performed: Job Title:

Date Employed From: To:

Starting Pay Rate: Ending Pay Rate:

Reason for Leaving:


Next Recent Employer:

Street Address

City State Zipcode

Phone No.: Supervisors Name:

Work Performed: Job Title:

Date Employed From: To:

Starting Pay Rate: Ending Pay Rate:

Reason for Leaving:


Please Read Each Paragraph Carefully, Initial Each Paragraph, and Electronically Sign Below

I hereby declare that I can perform the job-related functions applied for in this application. I further declare that the answers to the questions on this application are correct and that any misstatement of fact or omission could be cause for dismissal or rejection. I agree that any employment arrangement entered into is based upon the truthfulness of the statements that I have made herein. I understand I am a "Conditional Employee" until Family Home Care, Inc. has received verification of a satisfactory criminal background check and I have successfully obtained a Class II finger print card.
Electronically Initial

I understand this is a preliminary application and not a contract to employ me. In the event I am employed by Family Home Care, Inc., I further understand that my employment is for no fixed time and may be discontinued with or without cause or notice by myself or the company. I understand that no Employee or officer or agent of Family Home Care, Inc. may bind it by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above.
Electronically Initial

I understand that all FHC Employees will be given a drug and/or alcohol test as a condition of employment. FHC’s Drug-Free Workplace policy clearly states that the abuse of alcohol and illegal use of drugs will not be tolerated. This policy was designed with two basic ideas in mind: 1) Employees deserve a work environment that is free from the effects of alcohol and drugs and the problems associated with their use; and 2) FHC has a responsibility to our clients and our community to maintain a healthy and safe workplace. It is important for everyone to note that under State law, if a worker tests positive for alcohol or illegal drugs on a test that is conducted after a work-related accident (or refuses to take such a test after such an accident); the injury may not be compensable under the workers’ compensation system. In addition, as stated in FHC’s Drug-Free Workplace Policy, a positive test result, (or a refusal to undergo testing) also may result in disciplinary action by FHC, up to and including dismissal from employment. All employees are required to sign an acknowledgment, indicating that they have read understood, and will comply with the Drug-Free Workplace Policy.
Electronically Initial

I UNDERSTAND THAT IF EMPLOYED, I WILL BE SUBJECT TO THE FOLLOWING AND DO VOLUNTARILY ACCEPT "AT WILL" EMPLOYMENT UNDER THESE CONDITIONS.

One or more of the following conditions constitutes a voluntary quit and unemployment benefits may be denied.

1. Failure to call or report for work WITHOUT NOTICE prior to absence. Electronically Initial

2. Failure to call or report for reassignment after an authorized absence. Electronically Initial

3. Failure to notify Family Home Care, Inc. of a change of address or phone number. Electronically Initial

4. Refusal or failure to accept suitable work assignments. Electronically Initial

I understand that if employed, if medication is prescribed by a doctor for me to take, and the medication prescribed may impair my performance of my job related duties, or endanger other workers, I am required to so notify management of the specific medical problem and the exact drug that has been prescribed, prior to working any job assignment. Electronically Initial

I understand that if employed, I will be required to maintain current CPR and First Aid certifications while employed by Family Home Care, Inc. and am responsible for the costs incurred thereof. In addition, I will be required to maintain current and furnish verification for a Fingerprint Card, TB Test results, personal automobile insurance (if driving any vehicle for a client of for FHC), and a current copy of my driving record. Electronically Initial

Employment Verification

I hereby authorize Family Home Care, Inc. (FHC) to seek references from previous employers listed on this form, and to obtain a report from a government-reporting agency to be used for employment purposes. I authorize the references and previous employers listed to give FHC all information and opinions concerning me and my previous employment. I release all such parties from any liability which may arise from furnishing such information to FHC including, but not limited to, any liability for defamation or invasion of privacy. A photocopy of this consent and release will be valid as an original even though the photocopy does not contain an original writing of my signature. I certify that I have read, fully understand and agree with the foregoing certification statement. This authorization will expire one year after the date signed and noted below.

By entering my name and today's date below and submitting this form, I am indicating that I am electronically signing this form and have read the above statements; I have correctly filled out the Application to the best of my knowledge; and understand the content, intent and terms of this Application.

Name: (First Middle Last) Date Today:


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