Employment Application

Personal Information

Name (First, MI, Last)	Name:

Social Security Number:

DOB:

Address	Address:

City, State and Zip Code	City, State and Zip Code:

Telephone Number:

Alternate Telephone Number:

Email	Email:

Job Type

Days/hours available to work
I have no preference Monday Tuesday Wednesday Thursday Friday Saturday Sunday Day Evening Nights Overnights Live-In

I am seeking a: Full-time job Part-time job Full-time or Part-time job

How many hours can you work weekly?

Date available to begin:

Date of application:

Position applying for:

Additional Information

How did you hear about us?

Select one and provide details
Friend or family member	Name:
Current employee	Employee name:
Newspaper ad	Which newspaper?
Online	Which platform?
Other	Please specify:

Education

High School	Location	Years Completed	Major	Degree or Diploma

College or Trade School	Location	Years Completed	Major	Degree or Diploma

Licenses / Certifications

License/Certification	ID Number	Expiration Date	State Issued

Military

Have you ever been in the Armed Forces? YES NO	Date entered:
Are you now a member of the National Guard? YES NO	Discharge date:
Specialty:

Work Experience (start with most recent)

Company
Name of last supervisor
Hours / week
Address
City, State and Zip Code
Phone number
Start Date
End Date
Starting Salary
Final Salary
Your last job title
Reason for leaving (be specific)
Jobs held / duties / skills / promotions
May we contact this employer?	Yes No

Professional References

Name (First, MI, Last)
Title
Company
Phone Number
Address

Emergency Contact Information

Name (First, MI, Last)
Relationship
Home Phone Number
Cell Phone Number
Work Phone Number

Acknowledgement

By submitting this application for employment with New Hampshire Homecare Providers LLC, I authorize the company to verify all statements contained in this application and to contact previous employers and references listed herein. I understand that any false statements, omissions, or misrepresentations on this application may result in refusal to hire or immediate dismissal.

I certify that all answers and statements on this application are true and complete to the best of my knowledge.

Signature (typed):

Date:

Signature & Submit

Use mouse or touch to draw your signature below.

Attach Resume (optional)

Resume	Max 5 MB. Allowed: PDF, DOC, DOCX, TXT.

Have you been employed by this organization in the past? YES NO	I am a U.S. citizen / permanent resident / or authorized to work in the U.S. YES NO
Have you ever been convicted of a felony (guilty / no contest / withheld judgment)? YES NO If yes, please explain:
Do you have a driver’s license? YES NO	License details License #: State:
Accidents in last 3 years? YES NO	Moving violations in last 3 years? YES NO
Do you have an insurance policy on your vehicle? (required if transporting clients) YES NO