MB HOME CARE LLC
Employment Application
Applicant Information
Full Name:
Date:
Address:
City/State
ZIP Code:
Phone:
Email:
Date Available:
Desired Hourly Rate: $
Check Day Available:
Hours Available:
Are you a citizen of the United States?
If no, are you authorized to work in the U.S.?
Education
High School:
Address:
Did you graduate?
Diploma:
College:
Address:
Did you graduate?
Diploma:
Other:
Address:
Did you graduate?
Diploma:
MB HOME CARE LLC
References
Please list three (3) professional references not related to you who have knowledge of your work performance.
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Previous Employment
Please list below all present and past employers over the past ten (10) years, starting with your most recent employer, and account for all periods of unemployment. Attach additional sheets as necessary.
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary: $
Ending Salary: $
Responsibilities:
From:
To:
Reason for leaving:
May we contact your previous supervisor for a reference?
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary: $
Ending Salary: $
Responsibilities:
From:
To:
Reason for leaving:
May we contact your previous supervisor for a reference?
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary: $
Ending Salary: $
From:
To:
Reason for leaving:
May we contact your previous supervisor for a reference?
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary: $
Ending Salary: $
Responsibilities:
From:
To:
Reason for leaving:
May we contact your previous supervisor for a reference?
MB HOME CARE LLC
Additional Information
Identify any formal job training that pertains to this position:
Identify what skills and/or certifications you possess related to this position:
List any languages other than English that you can speak, read, or write that could be of benefit to the position you applied for:
Are you able to perform all of the essential functions of the job for which you are applying with or without reasonable accommodation?
If hired, are there any accommodations MB Home Care LLC would need to provide so that you can perform all those essential functions and duties of the position being applied for?
If yes, please explain:
If hired, do you have a reliable means of transportation to and from work?
If hired, would you be able to travel and/or work overtime as needed?
MB HOME CARE LLC
Background Check Questionnaire
Pursuant to Connecticut General Statutes § 20-678, MB Home Care LLC requires that all applicants for employment answer the following questions. Please note that you will be subject to a comprehensive background check in connection with your application for employment, and any false written statements regarding such prior criminal convictions or disciplinary action may subject you to criminal penalties.
1. Have you ever been convicted of any crime involving violence or dishonesty in any state or federal court in any state?
If yes, explain:
2. Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?
If yes, explain:
By signing below, I certify that the information I have provided is true and complete to the best of my knowledge.
Printed Name:
Signature:
Date:
MB HOME CARE LLC
Disclaimer and Signature
MB Home Care LLC (the “Company”) is an Equal Opportunity Employer. No one will
be denied employment on the basis of race, religious creed, color, national origin,
ancestry, age, sex, gender identity or expression, marital status, sexual orientation,
disability, or veteran status. MB Home Care LLC does not discriminate on any of the
aforementioned protected bases in the recruitment and employment of its staff and the operation of its business in accordance with state and federal laws and
regulations.
By signing your name below, you understand that nothing contained in this
application or in the interview process is intended to create an employment
contract between the Company and you. Should this application result in your
employment, you understand that any employment will be “at will,” meaning that
either you or the Company may terminate your employment at any time and for any reason, except for an illegal reason, with or without notice.
You certify that all statements made by you on this application are true and
complete to the best of your knowledge. By signing your name below, you acknowledge that you understand that misrepresentations, false statements or omissions may be cause for rejection of the application or for subsequent termination of employment if you are hired.
Further, you understand and affirm that any offer of employment with the
Company is contingent upon the successful completion of any required reference
checks, background checks, and/or physical examinations. By signing your name
below, you authorize former employer(s), reference(s), and any other individual or
organization to provide information solicited by the Company, and you agree to
release and discharge each of the above, including the Company, from any liability of any kind or nature.