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EMPLOYMENT REQUIREMENTS

Before completing an application, please answer the following questions.

Do you have a working phone number? Yes No
Are you able to lift 75 pounds or more? Yes No
Are you eligible to work in the United States? Yes No
Are you able to bathe a client? Yes No
Can you lift and use household equipment (vacuum cleaner, etc.)? Yes No
Can you repeatedly bend down to attend to a client (foot care, etc.)? Yes No
Can you transfer a client? (Bed to chair, etc.) Yes No
Would you be able to run, if needed? (Developmentally disabled childcare; autism, etc.) Yes No
Once you accept an assignment, are you committed to work out transportation difficulties if they arise? Yes No
Do you have a minimum of one professional reference? Yes No
Is your background free of criminal record? Yes No
Name: Date:

Thank you for your interest in Cambrian Homecare.

APPLICATION FOR EMPLOYMENT

 
Name: (Last, First) ,
Current Address:
City/State/Zip: ,
Telephone ( ) - - Make sure this is a phone line that is working. Make sure that you type in your entire phone number. This is how we will be contacting you.
Email:
Confirm Email:
Are you 18 years or older? Yes:      No:
Are you legally authorized to work in the United States? Yes:      No:

DESIRED EMPLOYMENT

Desired Position:

Are you applying to work with a specific client?
If yes, what is the name of the client?
Date you can start:
Salary desired:
Ever applied to this company before? Yes:    No:
If yes, where? when?
Ever worked for this company before? Yes:    No:  
If yes, where? when?

Who referred you to this company?


Please enter the Full name of the college, jobfair, employee or website if that was your choice on previous question:  

Region Applying for

EDUCATION

SCHOOL LEVEL NAME & LOCATION OF SCHOOL # YEARS ATTENDED DID YOU GRADUATE? SUBJECTS STUDIED
HIGH SCHOOL Yes No
COLLEGE Yes No
VOCATIONAL
TECHNICAL
TRADE
Yes No
OTHER Yes No

EXPERIENCE

Are you comfortable with house cleaning?Yes No
Do you Drive? Yes No
Have you cared for Hospice clients? Yes No
Have you cared for Alzheimer’s Clients? Yes No
Have you cared for Post-Op clients? Yes No
Do you know how to use a hoyer lift? Yes No
Are you allergic to pets? Yes No
Do you have a driver's license and transportation? Yes No

GENERAL
Subjects of special study or
research work:
    
Special training:     
Special skills:     
CPR Expiration Date:      (required)
TB Expiration Date:      (required)
FORMER EMPLOYERS
Name of present/last employer:
Address:
City/State/Zip: ,
Employment Start/Leaving Dates: -
Weekly Pay when you Started/Ended: -
Name of Supervisor:
Title:
Telephone
May we contact your supervisor? Yes:      No:
Your title/position:
Description of Work/Duties:
Reason(s) for leaving:
(Choose one and then explain)
Quit Voluntarily Terminated Laid Off
 
Name of previous employer:
Address:
City/State/Zip: ,
Employment Start/Leaving Dates: -
Weekly Pay when you Started/Ended: -
Name of Supervisor:
Title:
Telephone
May we contact your supervisor? Yes:      No:
Your title/position:
Description of Work/Duties:
Reason(s) for leaving:
(Choose one and then explain)
Quit Voluntarily Terminated Laid Off
 
Name of previous employer:
Address:
City/State/Zip: ,
Employment Start/Leaving Dates: -
Weekly Pay when you Started/Ended: -
Name of Supervisor:
Title:
Telephone
May we contact your supervisor? Yes:      No:
Your title/position:
Description of Work/Duties:
Reason(s) for leaving:
(Choose one and then explain)
Quit Voluntarily Terminated Laid Off
References
  Name Business/Organization Phone # Years Acquainted
1
2
3

Service Record 
Branch of Service
Rank
Description of Duties

Have you been convicted of a felony, violation or misdemeanor within the last 5 years? Yes:      No:
If yes, explain (will not necessarily exclude you from consideration)

Availability

Type of work desired: (check all that apply)
Senior Care Hourly AIDS clients
Hospice Short Visits Travel escort
Develop. Disabled children Sleepovers Develop. Disabled adults
Geographic areas willing to work: (check all that apply)
Los Angeles County: Orange County: San Bernardino County: Riverside County:
Long Beach area Anaheim area Ontario area Corona area
Los Angeles area Costa Mesa area San Bernardino area Palm Springs area
Norwalk area Santa Ana area Victorville area Hemet area
Torrance area South OC Barstow area Riverside area
All L.A. County North OC All San Bernardino Temecula area
  All Orange County   All Riverside County

Total number of hours you wish
to work each week
:
  SAT SUN MON TUES WED THURS    FRI
From
To

NOTIFICATION and AUTHORIZATION TO OBTAIN INFORMATION
APPLICANT COMPLETE AND SIGN THE FOLLOWING

  1. In connection with my application for employment, I understand that a consumer report or an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: worker’s compensation injuries, driving record, court record, education, credentials, credit and references.
  2. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
  3. Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.
  4. I acknowledge that this electronic agreement to authorize shall be as valid as the original. This release is valid for most federal, state and county agencies including the Minnesota Department of Labor.
  5. Minnesota, Oklahoma and California applicants only. If you want a copy of the report(s) ordered, check this box  [  ]  The report(s) will be sent by the reporting agency to you at the address below. The reports will be processed by: ADP Screening and Selection Services, 301 Remington Street, Fort Collins, Colorado 80524 and/or InfoLink Screening Services, Inc.
  6. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by CAMBRIAN HOMECARE or its agent, to furnish the information described in Section 1.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports.

By marking this checkbox, you are agreeing to the

terms above.


AUTHORIZATION

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 INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.

I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.

By marking this checkbox, you are agreeing to authorize this form.