Helping Hands Office Phone: 219-937-3390 Fax: 219-933-6657

Employment

Helping Hands Residential Services, LLC employees are compassionate, committed individuals who assist older adults with everyday tasks which promote the individual’s maximum level of independence. We want to ensure each consumer and their families that they will continue living independently or with family, by providing Attendant Care, Homemaker Services and Companion Care Services. We strive to provide assistance with activities of daily living, personal care, housekeeping, personal laundry, and companionship provided to an individual primarily in his or her personal residence, which are intended to provide a support system to enable that individual to remain safely and comfortably in his or her own personal residence.

Name:

Last:

First:

Middle:

Todays Date:

Address:

Street: Apt/Unit:

City:

State: Zip:

Phone:

Cell Phone:

Email:

Referred by:

Position applying for:

Date Available:

Type of employment desired:

Full-Time Part-Time Casual Specify Days and Hours:

If currenlty employeed, may we contact your employer? Yes No

Rate of Pay Expected

per hour

Is there a specific reason you are applying for employment at this company? Yes No

If yes, briefly outline the reason:

Are you legally eligible for employment in this country?

Yes No

Are you available to work overtime if required?

Yes No

Have you applied with this company before?

Yes No

Have you been employed at this company before?

Yes No

Do you have any friends or family employed at this location?

Yes No

If yes, when:

Location:

Have you been convicted of a crime in the last seven (7) years?

Yes No

If yes, please explain:

CONVICTION WILL NOT NECESSARILY BE A DISQUALIFICATION FOR EMPLOYMENT.

If considered for hiring, will you agree to provide a criminal background check?

Yes No

If considered for hiring, will you agree to provide a drivers abstract?

Yes No

What Nursing or relevant designations, licenses or registrations if any, do you possess?

Type

Date of most recent registration

Valid in state?

Yes No

Do you have the following certifications?

CPR:

Yes No

Last Certified:

First Aid:

Yes No

Last Certified:

Have you had a Tb test in the past year?

Yes No

PLEASE ANSWER THE FOLLOWING QUESTIONS

What was the best job you ever had and why?

What was your least favorite job and what did you dislike about it?

Think of the BEST supervisor you have ever had, what characteristics made that person a good manager?

Think of the WORST supervisor you have ever had, what characteristics made that person a poor manager?

Provide the following information beginning with the most recent employer.

MOST RECENT EMPLOYER:	TELEPHONE:	DATES EMPLOYED:
ADDRESS:		From:	To:
Summarize the type of work performed and the job responsibilities:
JOB TITLE:		HOURLY RATE/SALARY STARTING
Immediate supervisor name, title and phone number:		$	per:
		HOURLY RATE/SALARY FINAL
Reason for leaving:		$	per:
May we contact for reference? Yes No Later

2nd MOST RECENT EMPLOYER:	TELEPHONE:	DATES EMPLOYED:
ADDRESS:		From:	To:
Summarize the type of work performed and the job responsibilities:
JOB TITLE:		HOURLY RATE/SALARY STARTING
Immediate supervisor name, title and phone number:		$	per:
		HOURLY RATE/SALARY FINAL
Reason for leaving:		$	per:
May we contact for reference? Yes No Later

3rd MOST RECENT EMPLOYER:	TELEPHONE:	DATES EMPLOYED:
ADDRESS:		From:	To:
Summarize the type of work performed and the job responsibilities:
JOB TITLE:		HOURLY RATE/SALARY STARTING
Immediate supervisor name, title and phone number:		$	per:
		HOURLY RATE/SALARY FINAL
Reason for leaving:		$	per:
May we contact for reference? Yes No Later

4th MOST RECENT EMPLOYER:	TELEPHONE:	DATES EMPLOYED:
ADDRESS:		From:	To:
Summarize the type of work performed and the job responsibilities:
JOB TITLE:		HOURLY RATE/SALARY STARTING
Immediate supervisor name, title and phone number:		$	per:
		HOURLY RATE/SALARY FINAL
Reason for leaving:		$	per:
May we contact for reference? Yes No Later

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

Name

Relationship

Years Acquainted

Phone Number

I certify that all the information I have provided is true, complete and correct.

The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified.

I authorize this company to investigate all statements contained on this application. I understand that any misrepresentation or omission of facts is cause for immediate disqualification and/or if employed, immediate dismissal.

I understand that if I am hired, I will be to provide criminal background check at my cost, proof of identity and legal authority to work in the United States of America, proof of certifications or educational qualifications, and a drivers abstract (if applicable).

Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be by law. This application does not in any way constitute an agreement or contract for employment.

I AGREE

200 Russell St 8 floor Hammond, IN 46320