No Place Like Home Senior Care is an “Equal Opportunity Employer”. We consider all applicants for all positions without regards to Race, Sex, Religion, National Origin, Age, Marital or Veteran Status, medical conditions, and/or Disabilities.

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

City(Required)

State(Required)

Zip code(Required)

HomePhone(Required)

CellPhone(Required)

E-mail address(Required)

Best way to contact(Required)

Position applying for(Required)

SS#(Required)

Lowest acceptable wage Per(Required)

Date you can Start(Required)

MM slash DD slash YYYY

Are you available to work(Required)

Full-time

Part-time

Per-diem

All Referred by(Required)

Internet

Recruited

Walk-in

Other

please explain(Required)

Are you a U.S Citizen or Are you legally authorized to hold employment in U.S?(Required)

Yes

Are you at least 18 years of age or older?(Required)

Yes

Are you related to anyone who currently works for NPLH?(Required)

Have you ever worked for NPLH in the past?(Required)

Yes

When?(Required)

Please List Days and Hours you are available to work(Required)

Are you available for overnights?(Required)

Yes

Are you available for weekends?(Required)

Yes

Education Name and address of school Degree

High School(Required)

Yes

College(Required)

Yes

Trade/ Vocational Training(Required)

Yes

Other(Required)

Please list any additional or special education, training, skills(Required)

Do you have any disabilities that may limit your ability to perform the work in which you are applying?(Required)

Yes

Please explain(Required)

What can be done to accommodate your limitations?(Required)

Have you ever been convicted (found guilty) of a crime other than a minor traffic violation?(Required)

Yes

Please explain(Required)

Please List all former employers: A resume may not be submitted as a substitute for filling out this section. The information provided is subject to verification.

Company name

Position/Title

Address

City

State

Zip

Dates employed: From (month/year)

Dates employed: To (month/year)

Supervisor name

Title

Phone

May we contact

Yes

Starting rate of pay

Last rate of pay

Responsibilities

Reason for Leaving

If time elapsed between positions, please explain

Company name

Position/Title

Address

City

State

Zip

Dates employed: From (month/year)

Dates employed: To (month/year)

Supervisor name

Title

Phone

May we contact

Yes

Starting rate of pay

Last rate of pay

Responsibilities

Reason for Leaving

If time elapsed between positions, please explain

Company name

Position/Title

Address

City

State

Zip

Dates employed: From (month/year)

Dates employed: To (month/year)

Supervisor name

Title

Phone

May we contact

Yes

Starting rate of pay

Last rate of pay

Responsibilities

Reason for Leaving

If time elapsed between positions, please explain

I understand that if hired I would be required to offer documents proving that I am a U.S citizen, or an Alien currently authorized to work in the U.S. I also understand that my continued employment is contingent upon my proving the necessary documentation within the prescribed time frames.

Signature

Date

MM slash DD slash YYYY

This application will remain active for 6 months. Applicants who wish to be considered after that time must reapply.

Drug Testing

NPLH may conduct drug testing of job applicants. Should this company consider you for employment, you may be contacted regarding the time and location of the pre-employment drug test. Refusal to take or failing the drug test can disqualify you from further consideration of position.

Signature

Date

MM slash DD slash YYYY

I certify that all information is true to the best of my knowledge. I understand that all the information provided may be subject to verification and investigation by our company or a third party. I agree to conform to the rules and regulations of the company and supervisors.

Signature

Date

MM slash DD slash YYYY

List 3 Professional references

Name

Phone

Company

How long known

List 3 personal references

Name

Phone

Relationship

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