Job Application A Touch of Hand In-Home Care Services, LLC

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A Touch of Hand

In-Home Care Services, LLC

Request an Appointment

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Employment Application

Employment Application

Employment Form

Date of Application:

Date Available:

Availability: Check All That You Are Willing to Work:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Availability: Check All That You Are Willing to Work

Evening (5PM-9PM)

Nights (9PM-12MN)

Overnights

Position Applying For:

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Type of Employment Desired

Per Diem: Number of Hours:

Part Time: Number of Hours:

Full Time: Number of Hours:

Applicant Name:

Mailing Address:

Cell Phone:

Work Phone:

Email:

Language Skills Other Than English (Written/Spoken):

Have You Ever Been Employed Here Before?:

How Did You Hear About Us? Check as Applies:

Internet

Newspaper AD

Employee

Other

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Emergency Contact Information

Name:

Phone:

Relationship:

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Our agency is an equal-opportunity employer. All applicants and employees are considered for employment, advancement, and development based on their skills, performance, and potential.

No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap, or military status.

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Employment History - Please begin with your most recent or current place of employment.

Company:

Start Date:

Address:

Position:

Phone:

Supervisor:

Reason for Leaving:

Company:

Start Date:

Address:

Position:

Phone:

Supervisor:

Reason for Leaving:

Company:

Start Date:

Address:

Position:

Phone:

Supervisor:

Reason for Leaving:

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Education - High School

Name:

Course of Study:

Years Completed:

Date Graduated:

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Education - College

Name:

Couse of Study:

Years Completed:

Date Graduated:

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Education - Other

Name:

Course of Study:

Years Completed:

Date Graduated:

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Education - Other

Name:

Course of Study:

Years Completed:

Date Graduated:

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Military Service

Branch:

Dates:

Highest Rank Achieved:

Currently in a Reserve Unit?:

Special Schooling/Duties:

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License/Certifications

Name:

Expires:

State:

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Criminal History - By my signature below, I acknowledge/consent to a criminal check on my name.

Any record of founded child/dependent adult abuse or have you ever been convicted of a crime, in IA or any other state?:

Yes

No

If yes, explain:

Have you ever been convicted of violating any law? (Please omit minor traffic violations.):

Yes

No

If yes, please list conviction(s)/date(s)/location(s):

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The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. I attest that the above-referenced information is true and accurate to the best of my knowledge. I permit the agency to call any of my cited previous employers or reference candidates for information regarding my character, employment history, or work ethic.

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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SERVING

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and Surrounding Areas

HOURS

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BUSINESS HOURS

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Monday - Saturday OPERATIONAL HOURS

7:00 AM - 7:00 PM

CONTACT US

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