Employment Info

Interest in Open Position

YES! I am interested in employment with A Plus Quality Home Care. I understand that I may attach a resume to this form after completing the information requested below. I acknowledge that this is not an employment application. I also understand that I will be required to complete an employment application if scheduled for an interview.

Position of Interest:

Job Title:

Job #:

Facility:

Location:

Name: (First Middle Last)*

Address

City.

State:

ZIP Code.

Preferred contact phone:

Email.

Alternate contact phone:

Date available for work:

The position is:

Shift Availability

Are you currently excluded, debarred, suspended or otherwise ineligible to participate in any Federal programs?

Yes

Are you eligible to work in the U.S.?

Yes

Are you at least 18 years of age?

Yes

How did you learn of this position?

If other, please explain:

All licensed and/or certified positions require proof of current license or certification. Name on license/certification:

Name on license/certification:

License/Certification #:

State:

Brief summary of qualifications and/or relevant experience for position:(500 characters maximum)

EEO Information (Voluntary)

Gender:

Male

Female

Race

I hereby certify that the information in this form (and any accompanying documents) is true and complete to the best of my knowledge. I understand that any misrepresentation or failure to disclose information on this form may result in my disqualification from further consideration for employment or, if employed, my termination. I understand that the satisfactory completion of a background check, TB screen, and drug screen (conducted after an offer of employment) is a condition of employment with A Plus Quality Home Care DO NOT E-SIGN UNTIL YOU HAVE READ THE STATEMENT ABOVE. By my eSignature below, I certify that I have read, fully understand, and accept all terms of the foregoing statement. I consent to conducting this transaction electronically, and I agree that my eSignature has the same force and effect as my handwritten signature on this document. Equal Opportunity Employer Signature:

Date

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