| Name * |
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| E-mail Address * |
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| Adress * |
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| Phone * |
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| Are you a United States citizen? * |
Yes
No
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| Alien Registration Card #: |
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| Are you at least 18 years of age? * |
Yes
No
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| Vehicle-Make-Model |
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| Driver License # and Exp. * |
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| Do you have any traffic violations? * |
Yes
No
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| If so, explain. * |
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| Have you ever been convicted of a crime (other than traffic violations) or been imprisoned during the last seven years? A conviction will not necessarily bar you from employment |
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| Have you ever been bonded? |
Yes
No
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| Have you ever collected Workman’s Compensation? * |
Yes
No
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| This job may require you to get up and down from your knees and be able to lift up to twenty-five pounds. Do you have any physical or mental disability that may limit your performance in the job you are applying for? If so, what can been done to accommodate your limitation? * |
Yes
No
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| If so, what can been done to accommodate your limitation? * |
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| Employment Desired: Position: |
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| Date you can start: * |
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| Desired Salary: * |
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| Are you available to work full-time, Monday through Friday, 7:45 am until 5:00 pm? * |
Yes
No
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| Why do you want to be a house cleaner for Healthy Choice Home Care? * |
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| What special skills or qualities do you have that would make you both a good employee and a good house cleaner? * |
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| Are you interested in a position with Healthy Choice Home Care in the future such as Trainer, Team Leader or Promoter? |
Yes
No
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| Employment History:Beginning with the current or most recent employer: List position held, supervisors name, tel. and reason for leaving in addition to * |
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| Please give three references other than your past employers: * |
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I authorize investigation of all statements contained in this application. I understand that omission or misrepresentation of facts given is cause for dismissal. Further, I understand and agree that my employment is for no definite period of time and may, regardless of the date of payment of my wages and salary, be terminated at any time without previous notice. (check box) I agree.
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