Please Read and Sign Before Completing Application

Please Read and Sign Before Completing Application Please have your driver’s license, auto insurance and social security card ready so a copy can be m...
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Please Read and Sign Before Completing Application Please have your driver’s license, auto insurance and social security card ready so a copy can be made. Applicants must be at least 21 years old in order to apply due to Bonding/Insurance requirements. Applicant must pass drug screening and background check and have a current TB test.

 





Requirements for considering your application AUTO • You must have a dependable vehicle and current auto insurance. We require proof of insurance. REFERENCES • We require that our CAREGiver applicants supply us with the following:  3 professional and 3 personal references  Past employment history with contact names and telephone numbers  All references will be contacted and asked about your character and reliability. BACKGROUND CHECKS • To satisfy our bonding requirements we perform through checks for criminal history • Do not apply if your record is not clean • You will also be required to allow us to perform random drug/alcohol testing st • A payroll deduction of $25 will be deducted from your 1 check to cover the cost of the background checks, DMV check, initial and random drug/alcohol testing as needed to become a Home Instead CAREGiver. • Also, an additional $5 each pay period will be deducted as and administrative fee for updating those required documents yearly, as well as paying for your continuing education PAY • Direct Deposit into a checking or savings account is mandatory.

Home Instead Senor Care continues to thrive in today’s challenging economy due to many factors. Certainly not the least of which is the quality of our CAREGiver staff. This is one of the competitive advantages that we have over others in our industry. We hire only a small percentage of the total would-be applicants that inquire about our advertising. As you know we go through extensive measures in our hiring and training process to insure that our CAREGivers are truly the best. We are proud to say that we are successful in this effort. It would probably be no surprise to you that these efforts come at a great financial cost. It may surprise you, however to know just how much. Home instead Senior Care offices spend, on average, $650 to hire each CAREGiver. This cost is due to the cost of advertising and the new requirements placed on us by the state and by the HISC franchise system. State and federal background checks, random drug testing, and MVR’s are all required and are all very expensive. In addition many of these requirements are repeated on an ongoing basis during the year due to our bonding/insurance requirements. We hope that you understand. We don’t want to burden our CAREGivers but we have tried to keep the costs as low as possible - one $25 deduction and just $5 administration fee/ ongoing continuing education fee per paycheck after the initial $25. Thanks in advance for your understanding and for having a heart that leads you to serve the elderly.

I acknowledge that I have read and understood the above information. Applicant Signature:______________________________________ Date:_____________________

Each Home Instead Senior Care is independently owned and operated North Georgia Senior Care, LLC

EMPLOYMENT APPLICATION North Georgia Senior Care LLC d.b.a. an independently owned and operated Home Instead Senior Care® franchise Address: 211B Cleveland Street, Blairsville GA 30512 Phone: (706) 835-3800 INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.  Please read "Applicant Note” below.  Complete all pages of this application.  Print clearly. Incomplete or illegible applications may not be accepted.  If more space is needed to complete any question, use comments section on the back.  Application will be valid for 60 days. APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead Senior Care franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body is required prior to employment.

PERSONAL INFORMATION Today’s Date: ______________ Positions(s) Applied For: ____________________________________________________ Name: _______________________________ Last

_________________________________

_____________________

First

Middle

Current Address: _________________________________ Street

_______________________ City

______ State

____________ Zip Code

Home Phone: (______) ___________________

Work Phone: (______) ______________________

Cell Phone: (______) _____________________

Alternate Phone: (______) ____________________

Email address: _________________________________ Other Names Previously Used: ____________________________________ Last Name

__________________________________ First Name

____________________________________ Last Name

Middle Name

__________________________________ First Name

Emergency Contact(s): ____________________________________ Name

____________________ Middle Name

(______) ____________________ Phone

____________________________________ Name

____________________

(______) ____________________ Phone

Have you ever submitted an application here before? Yes / No If yes, when? _________________________________ Have you ever been employed here before? Yes / No If yes, when? ________________________________________

Each Home Instead Senior Care is independently owned and operated North Georgia Senior Care, LLC

You have been given a copy of the job description for the position for which you have applied. Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? Yes / No How did you hear about our Home Instead Senior Care franchise office? ___________________________________________ Why are you interested in employment with us? _____________________________________________________________ _________________________________________________________________________________________________

AVAILABILITY Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked. What date are you available to begin work? ___________ Please complete all areas of availability: ____Full-Time (30 or more hours/week) ____Part-Time (less than 30 hours/week) ____Mornings ____Afternoon _____Evenings ____Overnights ____Live-In ____Weekdays ____Weekends

Hours/Week Desired: _____

Please indicate the days of the week as well as the earliest and latest times that you are available for work. Monday Tuesday Wednesday Thursday Friday Saturday From: Shift 1 To: Shift 2

Sunday

From: To:

PREFERENCES Please indicate all counties in which you are willing to work: ___ Union ___ Fannin ___ Gilmer ___ Lumpkin ___ White ___ Towns ___ Habersham ___ Rabun ___ Stephens Please indicate the types of services which you are willing to provide: Companionship Meal Preparation Activities (games/crafts)

Housekeeping (dust/vacuum) Laundry/Ironing Medication Reminders

Errands/Shopping* Incidental Transportation* Dementia/Alzheimer’s Care

*In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required. Are you willing to provide service to a client with a pet? Yes / No If yes, which ones: ___Cats ___Dogs Are you willing to provide service to a client that smokes? Yes / No

JOB RELATED SKILLS Describe any training or life skills you have that apply to caring for a senior: ________________________________________ ________________________________________________________________________________________________ Describe any work history you have that would apply to caring for a senior: ________________________________________ ________________________________________________________________________________________________ What do you like (or think you would like) most about working with older adults? ___________________________________ ________________________________________________________________________________________________ What do you like (or think you would like) least about working with older adults? ___________________________________ ________________________________________________________________________________________________

Each Home Instead Senior Care is independently owned and operated North Georgia Senior Care, LLC

EDUCATION Please circle highest grade completed: Grade School: 6 7 8 School Type

High School: 9 10 11 12 School Name

College: 13 14 15 16 16+ City, State

Major/Subject

# Yrs Attended

Graduate

High School

Y/N

Vocational/Technical

Y/N

College/University

Y/N

WORK HISTORY Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential. MOST RECENT EMPLOYER Are you currently working for this employer? Yes / No __________________________________ Company Name

If yes, may we contact? Yes / No

________________________ City

Dates Employed: From ___________ to ___________

_______ State

( _____ )_______________________ Phone Number

_____________________________ Job Title

______________________________________ Supervisor's Name

______________________________________________________________________________________________________________________ Duties $_____________ per __________________ Salary (Hour, Week, Month)

____________________________________________________________________________ Reason for Leaving

SECOND MOST RECENT EMPLOYER ____________________________________ Company Name

________________________ City

Dates Employed: From ___________ to ___________

_______ State

_____________________________ Job Title

( _____ )_____________________ Phone Number

_______________________________________ Supervisor's Name

______________________________________________________________________________________________________________________ Duties $_____________ per __________________ Salary (Hour, Week, Month)

____________________________________________________________________________ Reason for Leaving

THIRD MOST RECENT EMPLOYER ____________________________________ Company Name

________________________ City

Dates Employed: From ___________ to ___________

_______ State

_____________________________ Job Title

( _____ )_____________________ Phone Number

_______________________________________ Supervisor's Name

______________________________________________________________________________________________________________________ Duties $_____________ per __________________ Salary (Hour, Week, Month)

____________________________________________________________________________ Reason for Leaving

Each Home Instead Senior Care is independently owned and operated North Georgia Senior Care, LLC

BACKGROUND As a condition of employment all employees must be “Bondable”. List states and counties of residence for the past seven (7) years: ________________________ State

____________________________ County

______________________ State

____________________________ County

________________________ State

____________________________ County

______________________ State

____________________________ County

Have you had any moving traffic violations? Yes / No If yes, please describe: _______________________________ Have you been convicted of a felony or misdemeanor in the past seven (7) years? Yes / No If yes, please describe: Incident City/State Result 1) _____________________________________________________________________________________________ 2) _____________________________________________________________________________________________

REFERENCES (Do not include relatives) Please complete all six references (three professional/three personal). Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance.

Full Name 1) 2) 3) 4) 5) 6)

H ( W( H ( W( H ( W( H ( W( H ( W( H ( W(

Phone Number ) ) ) ) ) ) ) ) ) ) ) )

Best Time of Day to Call AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM AM / PM

Relationship

Number of Years Known

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND North Georgia Senior Care LLC IS TERMINABLE AT-WILL, SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING. ________________________________________________________

____________________

APPLICANT SIGNATURE

DATE

Each Home Instead Senior Care is independently owned and operated North Georgia Senior Care, LLC

RELEASE AUTHORIZATION Name: ________________________________ Last

_____________________ First

___________ Middle Initial

Maiden/Previous Name(s): ______________________________________________________ Home Address: _______________________________________________________________ ______________________________________ City

____________________ State

___________ Zip Code

Social Security Number: _____________________ Date of Birth: ________________________ Driver’s License Number: ____________________ Issuing State: ________

Authorization to Secure Consumer Investigative Report I authorize North Georgia Senior Care LLC (Employer), d.b.a. an independently owned and operated Home Instead Senior Care franchise, to make whatever inquiries it may deem necessary in connection with my course of employment. As part of such inquiries, Employer has my permission to contact persons who may have information regarding my suitability for employment and to secure consumer reports (including investigative consumer reports). I authorize and instruct any person or agency contacted to participate or conduct inquiries at its request, to compile information, and to furnish any information obtained as a result of such inquiries. I further authorize Employer, in its sole discretion, to furnish copies of this authorization and my application to any person and/or consumer-reporting agency in connection with above purposes. Authorization for Drug Screening

I consent to drug testing designed to detect the presence of alcohol or the illegal use of drugs. Disclosure Statement Information contained in reports obtained by Employer in accordance with above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that Employer completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing within a reasonable period of time after your application for employment is received. I hereby acknowledge that I have read and understand the above disclosure statement. ______________________________________ Signature

_____________ Date

Each Home Instead Senior Care is independently owned and operated North Georgia Senior Care, LLC

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