* = Required Information

Applicant Information
Last Name:* First:* M.I.:
Street Address:*
Apartment/Unit #:*
City:*
State:* Zip:*
Phone:*
Alt.Phone/Cell #:
Date Available:
Position Applying For:
Desired Salary:
Are you a citizen of the United States? YesNo If no, are you authorized to work in the U.S.? YesNo
Have you ever worked for this company? YesNo If so, when?
Have you ever been convicted of a felony? YesNo If yes, explain
Days you are available to work:
Hours you are available to work:
Will you be able to work on short notice & weekends?
Do you have any responsibilities/commitments that may prevent you from working & meeting attendance requirements? if yes, explain:
How did you hear about us?
Do you know someone in need of our services?

if yes provide contact information:
Education
High School:
Address:
Did you graduate? YesNo Degree:
College:
Address:
Did you graduate? YesNo Degree:
References
Please list three professional references for the last five (5) years.
Full Name:
Relationship:
Company:
Phone:
( )  - 
Address:

Full Name:
Relationship:
Company:
Phone:
( )  - 
Address:

Full Name:
Relationship:
Company:
Phone:
( )  - 
Address:

Previous Employment
Company:
Phone:
( )  - 
Address: Supervisor:
Job Title:
Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving
May we contact your previous supervisor for a reference?: YesNo

Company:
Phone:
( )  - 
Address: Supervisor:
Job Title:
Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving
May we contact your previous supervisor for a reference?: YesNo

Company:
Phone:
( )  - 
Address: Supervisor:
Job Title:
Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving
May we contact your previous supervisor for a reference?: YesNo

Military Service
Branch: From: To:
Rank at Discharge: Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature
AUTHORIZATION:
I certify that the facts contained in this application for Dependable Home Healthcare, LLC, are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this applications shall be grounds for dismissal.
I authorize investigation of all statements contained and give full consent to the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by a company representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.
Signature: * Date:

* Security Code