Applications – Harris Home Care – Providing Compassionate Care, in Your Own Home!

Employee Information

Date:(Required)

Start Date:(Required)

Position Applying for:(Required)

Email:(Required)

Address:(Required)

Telephone:(Required)

Emergency Contact:

SS Number:

Date of Birth:(Required)

Education:

If yes, when:

Expiring Date:

Issuing State:

License #:

# of miles willing to travel:

Employment History

Please list in detail your entire work history. Begin with your current or most recent employer. Please explain any gaps in employment. PLEASE DO NOT complete this information with the notation “See Resume”. No more than 10 years recommended.

Employer name, address, Phone #

Position title/duties, skills:

Start Date:

End Date:

Pay:$

Per:

Supervisor:

Reason for Leaving:

Employer name, address, Phone #

Position title/duties, skills:

Start Date:

End Date:

Pay:$

Per:

Supervisor:

Reason for Leaving:

Employer name, address, Phone #

Position title/duties, skills:

Start Date:

End Date:

Pay:$

Per:

Supervisor:

Reason for Leaving:

Employer name, address, Phone #

Position title/duties, skills:

Start Date:

End Date:

Pay:$

Per:

Supervisor:

Reason for Leaving:

**Please note a brief explanation of any previous employer you wish NOT to be contacted**

Professional References

(ALL 3 References are required)

Full Name:(Required)

Title:(Required)

Company:(Required)

Phone:(Required)

Full Name:(Required)

Title:(Required)

Company:(Required)

Phone:(Required)

Full Name:(Required)

Title:(Required)

Company:(Required)

Phone:(Required)

Please read carefully and sign that you understand and accept this information
I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Harris Home Care, Inc. to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Harris Home Care, Inc. serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law.

If employed, I will be required to furnish proof of eligibility to work in the USA, to file a State security questionnaire and State loyalty oath, and to comply with company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off.

Penalty for Furnishing False Information – Any applicant for employment who willfully furnishes, supplies, or otherwise gives false information on an employment application that is the basis for a criminal history record check under this section shall be guilty of a Class A1 misdemeanor.

Date:(Required)

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Harris Home Care, Inc.

Application for Employment

Employee Information

Employment History

Professional References