Luxe Homecare

Application Form

Our company (“Luxe Homecare, Inc.”) fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with Disabilities Act a nd applicable federal, state and/or local laws, it is our policy to provide reasonable accommodation upon request during the application process to applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal, state and/or local employment laws and the information requested on this application will only be used for purposes consistent with those la ws. To the extent required by applicable law, The Company maintains a smoke-free workplace.

Salary Expectations *

Referred By

Personal Information

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Cell *

Phone *

Email Address *

If you are under 18 years of age, please specify your age:(This information will be used only for child labor law purposes).

Are there any days, shifts or hours you will not work? *YesNo

If Yes, please explain.

Are you available for out of town work? *YesNo

Do you have any allergies? *YesNo

Will you work overtime if required? *YesNoNote: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.

Number of Years you have been a CNA:0 / 5

Number of Years you have been a CHHA:0 / 5

Number of Years you have been a caregiver:0 / 5

Number of Years you have been an LVN Student:0 / 5

Types of clients you have worked with (Alzheimer’s, Dementia, Post surgical, Hospice, Etc.)0 / 200

Caregiver References: Please list two people you have provided care for in the past. (Name, Duration of Care, Tel.0 / 200

Can you accept a position immediately? *YesNo

If No, what date can you start?

How much weight can you lift? *

Work Availability: Monday Hours *0 / 30

Work Availability: Tuesday Hours *0 / 30

Work Availability: Wednesday Hours *0 / 30

Work Availability: Thursday Hours *0 / 30

Work Availability: Friday Hours *0 / 30

Work Availability: Saturday Hours *0 / 30

Work Availability: Sunday Hours *0 / 30

How did you learn of our company?0 / 30

Have you ever applied or worked at our company before? *YesNo

If yes, provide dates:

Are you legally authorized to work in the United States? *YesNoNote: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)? *YesNoNote: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

Please provide a copy of the following: *CPR/First aidTB Test ResultsLive Scan Results

Do you have a valid driver’s license? *YesNo

Education

Name of High School *

Graduated? *YesNo

If no, degree credits earned.

Type of degree *

Course of Study/Major *

Grade Point Average (GPA) *

Technical GED

Graduated?YesNo

Type of degree

If no, degree credits earned.

Course of Study/Major

Grade Point Average (GPA)

Licenses, certification, other

Name of College/University

Graduated?YesNo

If not, degree credits earned.

Type of Diploma/Degree received or expected.

Course of Study/Major and Minor *

Grade Point Average (GPA)

Name of College/University for Graduate School

Graduated?YesNo

If no, degree credits earned.

Graduate School Diploma/Degree received or expected

Course of Study/Major and Minor

Grade Point Average (GPA)

Employment History

Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.

Employment

Company Name *

Telephone *

Street Address *

Name of Supervisor *

May we contact? *YesNo

Dates employed: FROM - TO *

Reason for leaving: *

State job titles and describe job duties: *

Have you ever been discharged or asked to resign from employment? *YesNo

If yes, explain:

Did you receive any discipline in your last 12 months of active employment with your previous employer? *YesNo

If yes, explain:

Were you given a performance evaluation within the last 12 months of active employment? *YesNo

If yes, what was the range of scores used and what was your score?

Have you signed any non-competition or non-solicitation agreement or any other kind of agreement with any other employer that might restrict you from working for the Company (you will be required to furnish a copy of the agreement if you are being considered for hire)? *YesNo

If yes, please explain

Professional References

Name:

Street Address

Phone

Relationship

Military

(Complete only if you served in the military.)

Branch of service:

Number of years/months of service:

Rank at discharge:

Date of discharge:

Describe any military skills, training or experience you believe are relevant to the job you applied for:

I certify that the answers given herein and during the entire application process (including but not limited to any criminal record inquiries made following this application, resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge.

I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.

I consent to and authorize the Company to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment.

I further authorize the listed employers, schools and personal references to give the Company (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY B E TERMINATED BY ME OR THE COMPANY WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTE AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE COMPANY. I ALSO UNDERSTAND THAT MY AT-WILL EMPLOYMENT STATUS WITH THE COMPANY MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE OWNER, PRESIDENT OR CEO OF THE COMPANY.

I understand I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination; submit to a background investigation or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the release of any background check results and of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document.

I agree to sign any additional forms necessary for pre-employment checks and/or tests to be conducted.

CALIFORNIA APPLICANTS ONLY: I understand the Company may obtain, without using the services of a third party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics or mode of living during its evaluation of my application for employment and, if employed, during my employment.

By checking the following box, I waive my right to receive copies of public records obtained by the Company.Yes

Date *

Luxe HOMECARE

we offer specialized services to cater to specific conditions

Experience the Difference with Luxe Homecare. Call Us or Fill Out Our Online Form to Discover How We Can Support Your Family.

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Hospice Services

Senior Transportation

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Application Form

Luxe Homecare

Application Form

Personal Information

Education

Employment History

Professional References

Military

(Complete only if you served in the military.)

Luxe HOMECARE

we offer specialized services to cater to specific conditions

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