ALTRANAIS HOME CARE LLC
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Employee Application Form

    SECTION 1

    APPLICANT'S INFORMATION

    EMERGENCY CONTACT (person not living with you)

    GENERAL QUESTIONS

    EDUCATION

    EMPLOYEMENT HISTORY
    ​
    ---List the last THREE years employment history, starting with the most recent employer.
    EMPLOYER 1
    ​DATES OF EMPLOYMENT:
    Enter "CURRENT" if current job.
    EMPLOYER 2
    DATES OF EMPLOYMENT:
    Enter "CURRENT" if current job.
    EMPLOYER 3
    DATES OF EMPLOYMENT:
    Enter "CURRENT" if current job.
    If No, Enter N/A

    PROFESSIONAL REFERENCES
    Persons who can furnish information about job performance.
    PROFFESIONAL REFERENCE 1
    ​PROFFESIONAL REFERENCE 2
    PROFFESIONAL REFERENCE 3

    GENERAL
    NOTE: Conviction will not necessarily disqualify an applicant from employment.
    IF NO, ENTER N/A
    IF YES, ENTER N/A

    CREDENTIALS / SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

    SECTION 2



    ​DRIVER’S LICENSE
    Max file size: 20MB


    ​SOCIAL SECURITY CARD
    Max file size: 20MB


    AUTO INSURANCE
    Max file size: 20MB


    ​CPR CARD
    Max file size: 20MB


    PPD / TUBERCULOSIS
    Max file size: 20MB


    ​DIPLOMA / DEGREE OR  TRANSCRIPT
    Max file size: 20MB
    I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.
     
    I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.
     
    I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
     
    This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.
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  • Home
  • COVID-19
  • About
  • Services
  • Resources
  • Contact & Complaints
  • Satisfaction Survey
  • Employee Application Form