Employment Application | AAAHOMECAREINC

Position & Referral

Position applying for

Referral Source

Current Employee (if any)

Personal Information

Last Name

First Name

Middle

Email Address

Cell Phone

Current Address

How long at this address? (years)

Months

Alternate Number

Eligibility

Have you previously worked for this agency? Legally eligible to work in the United States? Reliable transportation to/from work? Relatives currently employed by this agency?

If yes, please list

Able to perform essential job functions with or without reasonable accommodations?

If no, describe limitations

Background

Have you ever been convicted of a crime or violation other than a minor traffic infraction?

If yes, please explain

Note: Do not enter Social Security Number, date of birth, or sensitive personal data on this form. We will request any required background-check details later through a secure process.

Availability

Select the shifts you are available to work.

Education

High School / GED (Name / City) Graduated?

College (Name / City) Graduated?

Graduate School (Name / City) Graduated?

Degree Type Subject

Employment History (last 3)

List your last three employers, assignments, or volunteer activities (most recent first).

Employer 1

Employer

Telephone

Address

Job Title

Supervisor & Title

Reason for Leaving

Pay

May we contact for reference / verification?

Employer 2

Employer

Telephone

Address

Job Title

Supervisor & Title

Reason for Leaving

Pay

May we contact for reference / verification?

Employer 3

Employer

Telephone

Address

Job Title

Supervisor & Title

Reason for Leaving

Pay

May we contact for reference / verification?

Professional References (3)

List three professional references that can verify character and quality.

Reference 1

Name

Title

Relationship

Years Known

Email

Phone

Address

Reference 2

Name

Title

Relationship

Years Known

Email

Phone

Address

Reference 3

Name

Title

Relationship

Years Known

Email

Phone

Address

I give my express permission to contact the references listed above.

Authorization

I authorize AAAHOMECARE Inc to request background-check information as required for the role (through a secure process). I understand that certain onboarding costs (e.g., TB test, background check) may be deducted from my first paycheck if applicable.

Applicant Signature (type your name)

Attachment (optional)