Apply Today | In-Home Care Positions | Application

Personal InformationPlease leave this field empty.

Name*

Phone Number*

Email*

Preferred Contact Method

How did you hear about Home to Stay?

SSN

Driver's License/ID Card Number

Driver's License/ID Card State

Residential Address

Street

City

State

Zip

Mailing Address

Street

City

State

Zip

If you are under 18, can you supply a work permit?

Emergency Contact Info

In case of an emergency, Home to Stay has my permission to contact:

Name (First and Last)

Full Address

Relation to You

Phone Number

Email

Employment Information

Desired Employment

Desired Position

Desired Start Date

Desired Salary (per hour)

Are you employed now?

If so, may we contact your current employer?

Have you ever applied to or worked for Home to Stay prior to this application?

If so, when?

And for/in what position?

Will you travel if required?

How far (in miles)?

Will you work overtime if needed?

Are you able to meet the attendance requirements of this position?

Have you been convicted of a felony in the past 7 years?

If yes, explain (Note: Such conviction may be relevant if job related, but may not bar you from employment.):

Education Information

Academic Institutions

Currently Attending

Name of School

Location of School

Did you graduate?

Area of Study

Certification/Licensure Received

Last Completed

Name of School

Location of School

Did you graduate?

Area of Study

Certification/Licensure Received

Trades or Business

Currently Attending

Name of School

Location of School

Did you graduate?

Area of Study

Certification/Licensure Received

Last Completed

Name of School

Location of School

Did you graduate?

Area of Study

Certification/Licensure Received

Summarize any special skills and qualifications acquired from other employment or experiences that may qualify you to work with Home to Stay:

Reference Information

Previous Employment:

Employment 1

Name of Employer

Phone Number of Employer

Employed From

Employed To

Job Title

Salary (per hour)

Reason For Leaving

Employment 2

Name of Employer

Phone Number of Employer

Employed From

Employed To

Job Title

Salary (per hour)

Reason For Leaving

Employment 3

Name of Employer

Phone Number of Employer

Employed From

Employed To

Job Title

Salary (per hour)

Reason For Leaving

Personal References

Please list 3 persons, not related to you, whom you have known for at least 1 year.

Reference 1

Name

Phone Number

How/From where do you know them?

How many years have you known them?

Reference 2

Name

Phone Number

How/From where do you know them?

How many years have you known them?

Reference 3

Name

Phone Number

How/From where do you know them?

How many years have you known them?

Foreign Language(s)

List any foreign language(s) and select the option that best describes your skill level.

Language 1

Language

Skill Level

Language 2

Language

Skill Level

Conditions of Employment-

Please read carefully and initial each term of employment. Sign and date at the completion of this application.

Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant/employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separate from the employer’s service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.

I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on the basis prohibited by local, state or federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel or mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

This application is current for 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. After 60 days, if I have not proceeded forward in the hiring process, it will be necessary to fill out a new application. With my signature below, I attest to the fact that all of the information that I provided on this application is accurate, correct, and truthful to the best of my knowledge.

Additional Notes/Comments:

Please list any explanations from above or any other information:

Sign & Date

Signature (enter full name to act as signature)

Date