DELTA HOMECARE
AN EQUAL
OPPORTUNITY EMPLOYER
APPLICATION FOR EMPLOYMENT
OR FOR CONTRACT SERVICES
DRUG FREE
WORKPLACE

 
TODAY'S DATE
05-20-2012		 E-MAIL (LEAVE BLANK IF NONE)
 PHONE NUMBER
() -		 ALTERNATE PHONE NUMBER
() -
LAST NAME
 FIRST
 MIDDLE INITIAL
STREET ADDRESS
 CITY
 STATE
 ZIP CODE
PREVIOUS ADDRESS
 CITY
 STATE
 ZIP CODE
SOCIAL SECURITY #
--		 DRIVER'S LICENSE #
 STATE THAT ISSUED LICENSE
 
ARE YOU 18 OR OLDER?           YES NO

DO YOU HAVE UNITED STATES CITIZENSHIP OR AUTHORIZATION FROM THE IMMIGRATION & NARTURALIZATION SERVICE TO WORK
IN THE US?                                 YES NO

NOTE: If hired, federal law requires that you furnish documentation establishing your identity and eligibility to work in the United States.

 
POSITION APPLYING FOR:
DO YOU WANT FULL-TIME?
     YES NO
WILL YOU ACCEPT PART-TIME?
     YES NO		 NUMBER OF HRS DESIRED
PER WEEK: 		RATE OF PAY
DESIRED:
HAVE YOU EVER APPLIED OR BEEN EMPLOYED BY DELTA HOMECARE?      YES NO
IF YES, LIST WHEN:      
WHAT OTHER EMPLOYMENT DO YOU HAVE?
 WOULD YOU CONTINUE THIS IF EMPLOYED BY DELTA?
     YES NO
HAVE YOU EVER BEEN CONVICTED OF A CRIME?      YES NO
IF YES, EXPLAIN:      
HOW WERE YOU REFERRED
TO DELTA HOMECARE?
 EMPLOYEE FRIEND
NAME:
 NEWSPAPER AD OTHER
EXPLAIN:
LIST ANY FRIENDS OR RELATIVES WORKING FOR DELTA:
(LEAVE BLANK IF NONE)		 NAME:
RELATIONSHIP:
 
EDUCATION / COURSE OF STUDY
TYPE OF SCHOOL
NAME AND LOCATION OF SCHOOL
DATES
GRADUATE?
STUDY/DEGREE
High School
  YES NO
Technical, Business, or Other
(LEAVE BLANK IF NONE)
From: To: YES NO
College or University
(LEAVE BLANK IF NONE)
From: To: YES NO
FOR INTERVIEWER'S USE ONLY
DATE INTERVIEWED:


 INTERVIEWER:


 AVAILABLE START DATE:


 COUNTIES APPLICANT CAN WORK IN:
APPLICANT
TIME
AVAILABILITY
DAY SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
    FROM
      TO
( ) REFERENCE                ( ) DRUG SCREEN                ( ) TB                ( ) PHYSICAL                ( ) CPR/1ST AIDE                ( ) DRIVER'S LICENSE
      ( ) CERTIFICATION                ( ) INSURANCE CARD                          ( ) SOCIAL SECURITY CARD

GENERAL APPLICANT INFORMATION:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
 
EMPLOYMENT HISTORY
LIST BELOW PAST AND PRESENT EMPLOYMENT BEGINNING WITH YOUR MOST RECENT, INCLUDE U.S. MILITARY EXPERIENCE.
EMPLOYER 1
COMPANY
DATES OF
EMPLOYMENT
PAYRATE
POSITION HELD
JOB TITLE
REASON FOR LEAVING
ADDRESS, CITY, STATE
 FROM:


TO:
 UPON STARTING
IMMEDIATE SUPERVISOR
 UPON LEAVING
 FULL-TIME PART-TIME
SUPERVISOR TITLE
 MAY WE CONTACT THIS EMPLOYER?



YES NO
JOB RESPONSIBILITIES
WORK TELEPHONE
() -
 
EMPLOYER 2
COMPANY
DATES OF
EMPLOYMENT
PAYRATE
POSITION HELD
JOB TITLE
REASON FOR LEAVING
ADDRESS, CITY, STATE
 FROM:


TO:
 UPON STARTING
IMMEDIATE SUPERVISOR
 UPON LEAVING
 FULL-TIME PART-TIME
SUPERVISOR TITLE
 MAY WE CONTACT THIS EMPLOYER?



YES NO
JOB RESPONSIBILITIES
WORK TELEPHONE
() -
 
EMPLOYER 3
COMPANY
DATES OF
EMPLOYMENT
PAYRATE
POSITION HELD
JOB TITLE
REASON FOR LEAVING
ADDRESS, CITY, STATE
 FROM:


TO:
 UPON STARTING
IMMEDIATE SUPERVISOR
 UPON LEAVING
 FULL-TIME PART-TIME
SUPERVISOR TITLE
 MAY WE CONTACT THIS EMPLOYER?



YES NO
JOB RESPONSIBILITIES
WORK TELEPHONE
() -
 
ANY PERIODS OF UNEMPLOYMENT?    YES NO
IF YES, PLEASE EXPLAIN AND GIVE DATES:
PLEASE LIST ANY SKILLS, ABILITIES, HOBBIES, TRAINING, ETC. WHICH YOU FEEL MAY BE AN ASSET.
PLEASE READ THE FOLLOWING AND SIGN BELOW:

I acknowledge that the facts set forth on this application are true and complete. I understand that if employed, any false statement or omission on this application or any attachments shall be sufficient cause for dismissal. I understand that all Delta Homecare clients must be seen regardless of circumstances and that, if I am employed by Delta Homecare, I may be scheduled to work any time or day of the week, including holidays.

I understand that before I am hired, Delta Homecare may require me to undergo a physical examination (after a conditional job offer) and/or a drug or alcohol test. I agree to take such an examination and/or test. I also understand that if I am hired, Delta Homecare may require me to undergo a drug and/or alcohol test at any time during my employment. I agree to take such a test.

I authorize Delta Homecare to use its personnel or any investigative agency to investigate my employment record, education, and criminal conviction record. I also authorize all my employers and former employers, educational institutions, and any other persons contacted by Delta Homecare representatives to provide Delta Homecare with all records and information relevant to my employment application with Delta Homecare. I release all parties who provide such records or information from all liabilities arising from such disclosures; and I waive any right to notice of such disclosures.

I authorize Delta Homecare to copy this document and agree that such copies with my signature shall have the same legal force and effect as the original document with my signature.

SIGNATURE                     DATE

By typing your name in the "SIGNATURE" box above and submitting this information to us, you declare that this submitted document and printed copies with my digital signature shall have the same legal force and effect as an employment application with my handwritten signature.

DELTA HOMECARE WISHES TO EXPRESS ITS APPRECIATION TO YOU FOR CONSIDERING US AS A POTENTIAL EMPLOYER.