Lares Home Care Application

Let's Start with Some Basic Info About You.

First Name

Last Name

Email *

Phone *

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Street Address *

City *

State *

Country

Postal code *

How Long Have You Been at This Address? *

Social Security Number *

What Position Are You Applying For? *

Available Start Date *

Are You Currently Employed? *

Do You Prefer Full-Time or Part-Time Employment? *

Total Hours Desired Each Week *

What Days Are You Available to Work? (Select All That Apply) *

When Are You Available to Work? (Select All that Apply) *

Are You Available to Work (Select All That Apply) *

Are You Available to Work Overtime? *

Now Tell Us About Your Educational Background

High School

High School Name and Location

Did You Graduate High School?

Date of Graduation from High School

Technical School

Technical School Name and Location

Did You Graduate from Technical School?

Date of Graduation from Technical School

Type of Degree from Technical School

College or University

College or University Name and Location

Did You Graduate from College or University?

Date of Graduation from College/University

Type of Degree from College/University

Post-Graduate Education

Post-Graduate Studies Name and Location

Did You Graduate from Post-Grad Degree?

Type of Degree from Post-Graduate Studies

Date of Graduation from Post-Graduate Studies

Other Education

List Locations/Dates/Degrees from Other Educational Opportunities

Military Service

Have You Served in the U.S. Military?

Licenses/Certifications

Do you have any Licenses, Certifications, or other credentials to work in the position for which you have applied?

Professional Licenses

Profession (1)

Expiration Dates (1)

Verification (1)

License Number (1)

Profession (2)

License Number (2)

Expiration Dates (2)

Verification (2)

Para-Professionals

Para-Professional Certification(s)

School or Training Program (1)

Verification (HHA PCA CNA) (1)

School or Training Program (2)

Verification (HHA PCA CNA) (2)

Employment History

Please list all previous employment, beginning with the most recent. Incomplete information could disqualify you from further consideration.

Former Employer #1 Company Name

Former Employer #1 Full Address

#1 Start Date

#1 End Date

#1 Position Held

May We Contact Former Employer #1?

Former Employer #2 Company Name

Former Employer #2 Full Address

#2 Start Date

#2 End Date

#2 Position Held

May We Contact Former Employer #2?

Former Employer #3 Company Name

Former Employer #3 Full Address

#3 Start Date

#3 End Date

#3 Position Held

May We Contact Former Employer #3?

Former Employer #4 Company Name

Former Employer #4 Full Address

#4 Start Date

#4 End Date

#4 Position Held

May We Contact Former Employer #4?

Former Employer #5 Company Name

Former Employer #5 Full Address

#5 Start Date

#5 End Date

#5 Position Held

May We Contact Former Employer #5?

References

Reference #1 Full Name

Reference #1: Phone

Reference #1 Relationship

Reference #2 Full Name

Reference #2: Phone

Reference #2 Relationship

Reference #3 Full Name

Reference #3: Phone

Reference #3 Relationship

How Did You Hear About Us?

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

Have you have been given a copy of the job description for the position for which you have applied to review. *

Have you ever used any other name(s) which is (are) necessary for us to know in order for us to verify your employment or educational record? *

If yes, please explain when and if you were employed.

Have you previously worked for or applied for a position with Lares Home Care, in any of our locations either as an employee or through an employment agency? *

If yes, please provide the other name(s).

Malpractice Insurance Information

Do you currently hold malpractice insurance? *

Malpractice Insurance Carrier

Malpractice Insurance Address

Malpractice Insurance Policy Number

Accept Authorization *

I certify that all the information furnished on this application and during the application process is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts called for may result in refusal to hire or, if hired, may result in my dismissal at any time regardless of when the false answer or omissions are discovered. I recognize that this employment application is not an offer of employment. I agree that if I am hired by the Company, I will be an at-will employee, meaning that either the Company or I may end the employment relationship at any time with or without cause or notice. I understand that only the Human Resources of Lares Home Care, and no manager, supervisor, or other representative of the Company, has authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the at-will employment relationship, and with respect to any agreement entered into by the Human Resources, any such agreements must be in writing and signed by the Certified Home Health Aide and by me or my authorized representative. I further understand and agree that, except for my at-will employment status, if hired, my wages, hours, working conditions, job assignment(s), and compensation rate(s) will be subject to change by Lares Home Care. I understand that the Company may share the information contained in this application with other Company employees for employment and administrative purposes and hereby consent to such transfer I hereby authorize, to the extent allowed by applicable federal state and local laws, Lares Home Care to conduct its own investigation of my references, employment history and education and, further, authorize the references and prior employers I have listed to disclose to the Company information related to my employment history and qualifications for the position for which I am applying, without giving me prior notice of such disclosure. I understand and expressly agree that if employed by the Company, storage areas provided for me (locker, desk, etc.) are open to investigation by the Company without prior notice to me. I understand that the Company may not ask or require applicants to disclose past salary, wages or other compensation I, (Applicant), hereby authorize Lares Home Care to request and receive from all prior employers within one year of the date of this application , any and all pertinent information concerning my prior employment and its termination, including the reason for such termination.

Sign Here *

Clear