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PERSONAL INFORMATION
Position(s) Applied For
*
Name
*
First
Last
Home Phone
*
Work Phone
*
Cell Phone
*
Email
Current Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Contact
Name
*
First
Phone
*
Emergency Contact 2
Name
*
First
Phone
*
Valid Driver’s License #
*
State Issued
*
State Issued
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Expiry Date
*
MM slash DD slash YYYY
Make & Model of Vehicle
*
Year of vehicle
*
Auto In Co
*
Policy #
*
Expiry Date
*
MM slash DD slash YYYY
Have you Ever Applied Here?
Have you Ever Applied Here?
Yes
No
When
Have you ever been employed here before?
Have you ever been employed here before?
Yes
No
When
How did you hear about us?
Have you been given a copy of the job description for the position for which you have applied to review?
Have you been given a copy of the job description for the position for which you have applied to review?
Yes
No
Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?
Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?
Yes
No
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 number of hours worked.
What date are you available to begin work
*
MM slash DD slash YYYY
Please complete all areas of availability:
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Select All
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
Sunday
Add
Remove
PREFERENCES
Please indicate all areas of the city in which you are willing to work:
*
Cobb County
Cherokee County
Clayton County
Dekalb County
Douglas County
Fayette County
Forsyth County
Fulton County
Gwinnett County
Hall County
Select All
Please indicate the types of services which you are willing to provide:
*
Companionship
Housekeeping (dust/vacuum)
Errands/Shopping/Transportation*
Meal Preparation
Laundry/Ironing
Personal Care
Activities (games/crafts)
Medication Reminders
Dementia/Alzheimer’s Care
Select All
*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?
Are you willing to provide service to a client with a pet?
Yes
No
Which ones
Cat
Dogs
Both
Are you willing to provide service to a client that smokes?
Are you willing to provide service to a client that smokes?
Yes
No
JOB RELATED SKILLS
Describe any work history you have that would apply to caring for a senior
Describe any training or life skills you have that 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?
What personal rewards do you get from working with seniors?
EDUCATION
Please check highest grade completed
*
Grade School: 6 7 8
High School: 9 10 11 12
College: 13 14 15 16 16+
Details
*
School Type
School Name
City/State
Major/Subject
# Yrs. Attended
Graduate (Y/N)
Add
Remove
*For employment our minimum education requirement is either a GED or High School diploma
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
*
Are you currently working for this employer
Yes
No
May we contact?
*
May we contact?
Yes
No
Compnay Name
City
State
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Employer Phone
Date Employed From
*
MM slash DD slash YYYY
Date Employed To
*
MM slash DD slash YYYY
Job Title
Supervisor's Name
Duties
Salary (Mention Per Hour, Week, or Monthly)
Reason for Leaving
SECURITY
*******Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.
As a condition of employment all employees must be “Bondable” & “Insurable”. Are you at least 19 years of age?
As a condition of employment all employees must be “Bondable” & “Insurable”. Are you at least 19 years of age?
Yes
No
List states and counties of residence for the past seven years:
Have you had any moving traffic violations
Have you had any moving traffic violations
Yes
No
Describe Details
Have you been charged/convicted of a felony and/or misdemeanor/or served time
Have you been charged/convicted of a felony and/or misdemeanor/or served time
Yes
No
Please Describe Details
*
Incident
City / State
Charge
Add
Remove
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?
Yes
No
REFERENCES (Do not include relatives)
Please complete all six references. Your application will not be considered unless six references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 6 references, you will be asked to provide additional references.
References List
*
Full Name
Phone #
Best time of Day for Call AM/PM
Relationship
Number of Years Known
Add
Remove
CERTIFICATION AND RELEASE:
*
CERTIFICATION AND RELEASE:
*
I certify that I have read and understand the applicant note on page one (1) 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. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Rasmussen Home Care, and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed
PRINT APPLICANT NAME AS SIGNATURE
*
Date
*
MM slash DD slash YYYY
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blissqualityhomecare@gmail.com
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