Huser HomeCare Employment

Online Employment Application

First Name: Middle Name: Last Name:

Street Address:

City: State: Zip Code:

County: Have you lived in this county over 3 years? Prior County:

Daytime Phone Number: Evening Phone Number:

Cell Phone: E-mail:

Position Applied For:

Date Available to Start Work: Are you at least 18 Years of Age?

Desired Salary or Hourly Wage: Do you want:

What Shifts Will You Work?

Are You Willing to Work Weekends? Are You Willing to Work Holidays?

Specialty Certificates:

State Registration or Certificate Number:

Registered/Licensed/Certified in another state?

If so, specify State and Date:

Do You Have a Legal Right to Work in the United States? If No, Explain:

What Special Equipment or Machines Can You Operate?

Comments/Special Skills (e.g., qualifications, training, conversational language skills, sign language):

Employment History: Failure to provide complete and accurate information on references and employers

could result in your application being refused for consideration. Please begin with your current or most recent employer.

Dates of employment: From: To: Final Pay Rate:

Company Name: Phone No:

Address, City, State, ZIP:

Supervisor's Name: Phone No:

Position(s) Held:

Reason for leaving:

Dates of employment: From: To: Final Pay Rate:

Company Name: Phone No:

Address, City, State, ZIP:

Supervisor's Name: Phone No:

Position(s) Held:

Reason for leaving:

Dates of employment: From: To: Final Pay Rate:

Company Name: Phone No:

Address, City, State, ZIP:

Supervisor's Name: Phone No:

Position(s) Held:

Reason for leaving:

References:

Name: Address:

Email: Phone: Years Known:

Relationship:

Name: Address:

Email: Phone: Years Known:

Relationship:

Name: Address:

Email: Phone: Years Known:

Relationship:

Name: Address:

Email: Phone: Years Known:

Relationship:

Education:

High School

Name: Location: Graduate?

Degree Received:

Technical School

Name: Location: Graduate?

Degree Received:

College/University

Name: Location: Graduate?

Degree Received:

College/University

Name: Location: Graduate?

Degree Received:

Other Information:

Have you ever been discharged from any position?

If Yes, explain:

Have you ever been convicted of a felony:

If Yes, explain:

Referred to Huser HomeCare by:

Read Carefully Before Agreeing To The Following:

Falsification, misrepresentation or omission of information requested in this application may subject me to immediate

dismissal. It is my understanding that Huser HomeCare will make a thorough investigation of my work and personal

history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize

such investigation and the giving and receiving of any information requested by the agency, and I release from

liability any person giving or receiving any such information. I understand that falsification of data so given or other

derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may

subject me to immediate dismissal.

I understand that my employment depends on satisfactory references and background checks, successful completion

of competency testing, and any physical examination that may include testing for the use of illegal substances.

I also acknowledge and understand that this employment application is not a contract of employment and that, if

I am hired, I will be an at-will employee and I may voluntarily leave my employment upon proper notice or my

employment may be terminated at any time for any reason. I acknowledge that no written or oral statements or

promises have been made to or relied upon by me regarding the length of my employment or the reasons for which

my employment may be terminated.

If hired, I agree to abide by and conform to the rules, policies, and procedures or Huser HomeCare. In consideration

of Huser HomeCare employing me, I agree that I will not seek or accept employment (either directly or indirectly

in any capacity) for at least twelve (12) months after the last day of service by Huser HomeCare from any client

of Huser HomeCare to whom I have been assigned, without the express written approval of Huser HomeCare's

President.

By checking this box, I agree to the terms stated above. Date:

HUSER HOMECARE CONSIDERS ALL APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, OR HANDICAP.

Employee Reference / Authorization to Release Information

I, the undersigned, hereby authorize Huser HomeCare, my prospective employer, to obtain information about me from personal references, previous employers, schools, Bureau of Motor Vehicles and/or law enforcement agencies. I authorize my personal references, previous employers, schools that I have attended, Bureau of Motor vehicles and law enforcement agencies to disclose such information about me as Huser HomeCare may request. I further authorize my personal references, previous employers or schools to candidly disclose to Huser HomeCare all facts and opinions concerning my academic or work performance, dependability, cooperativeness, attitude and ability to get along well with others. Further, I release those individuals, schools or companies and any person completing this form from any and all liability from supplying the requested information.

By checking this box, I agree to the terms stated above. Date: