Do you have a Valid CNA or HHA License in PA or NJ? If yes, please list your license #.

How did you hear about us?

What Days and Times are you Available to Work?

What shifts do you prefer (Mornings, Afternoons, Evenings, Overnight)?

Do you drive? If yes, do you have consistent access to reliable transportation?

READ CAREFULLY BEFORE SIGNING I hereby certify, to the best of my knowledge that the answers given are true and complete. I also understand that an omission or falsification may disqualify me from consideration for employment or may be grounds for my immediate dismissal. I agree to conform to the rules and regulations of the company and, if employed, I understand and agree that my employment is at-will and that no employment contract rights have been created. I also understand and agree that my employment may be terminated at any time with or without cause, and with or without advance notice at the option of either the company or myself. I understand that no supervisor, manager, or other representative of the company has any authority to enter into any express or implied contract for employment for any specific period of time. Any agreement contract to the above must be in writing and expressly state that is a contract and be signed by the authorized representative of the company. I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position will prevent my employment with the company. I also understand that employment, for certain positions, is conditional upon successful completion of a substance abuse screening test as part of the company’s pre-employment policy. IMMIGRATION ACT I understand that, if hired, I will be required to offer examination documents proving that I am a United States citizen, or an alien currently authorized to work in the United States. I also understand that my continued employment is contingent upon my proving the necessary documentation within the prescribed time frames. AN EQUAL OPPORTUNITY EMPLOYER We are an Equal Opportunity employer in accordance with the Civil Rights act of 1964, and therefore comply with the law prohibiting discrimination on such factors as race, color, religion, sex, national origin, marital or veteran status, or disability. Under the Pennsylvania Human Relations Act, an employer has a legal obligation to accommodate an employee’s or job applicant’s handicap unless the accommodation would impose an undue hardship on the employer. A handicapper may allege a violation against an employer regarding a failure to accommodate his or her handicap only if the handicapper notifies the employer in writing of the need for accommodation within 180 days after the date the handicapper knew or reasonably should have known that an accommodation was needed. DRUG TESTING The company may conduct drug testing of job applicants. Should you be considered for employment by this company, you may be contacted regarding the time and location of the pre-employment drug test. Refusal to take the drug test or failing the drug test can disqualify you from further consideration for a position. AUTHORIZATION AND UNDERSTANDING I certify that the information given herein is true and complete without qualification. I understand that the company may investigate my work and personal history and verify all data given on this application, on related papers, and in interviews, and I authorize your company to do the same. This inquiry may include information as to my character, general reputation, and personal characteristics, and I consent to the conduct of this inquiry and to the consideration of any statements of references or former employers that are given in response to the inquiry. I authorize all individuals, schools, and employers named therein, except as specifically limited on this application, to provide information requested about me, and I release them from liability for damages in providing this information. I understand and acknowledge that your company can terminate my employment if I have provided incomplete, inaccurate, untrue or misleading information in this application or on any other document or form at any time during my employment. I give authorization to have my personal credit history, criminal history and driving record investigated by a third party. If terminated, I authorize your company to use any information in its possession concerning me for reference purposes and/or if legally required to furnish any information, including disclosure of information to any third party., future employer or prospective employer, without receiving any prior notice, and I release your company from any liability in connection with such use or disclosure. In consideration of my employment, I agree to conform to the rules and regulations of your company, and the directions of its Supervisors. I understand and acknowledge that, if employed, unless my employment becomes subject to a collective bargaining agreement, my employment and compensation will be at the will of the company and can be terminated, with or without cause, and with or without notice, at any time at the option of either the company or myself. I further understand and agree that no manager, representative agent or employee of the company, other than the President, has now or has had in the past any authority to enter into any agreement for employment for any specified period of time or to make any agreement which is contrary to or a modification of the above described employment relationship, and that any such agreement or representation must be in writing and signed by both myself and the President of the company in order to be effective. I further understand that my employment is conditional until such time as the results of any pre-employment drug testing, if any is required, are known. I also understand and acknowledge that, as a part of the hiring process and throughout my employment, if hired, I may be required to submit to medical/physical examinations at the employer’s discretion and expense. SOCIAL SECURITY NUMBER MAINTENANCE & VERIFICATION POLICY Federal tax regulations require us to request an SSN from every employee to whom compensation is paid. Employee SSNs are maintained and used by In-Home Care, Inc. for payroll and benefits purposes, to verify employment history, and are reported to Federal and state agencies on forms required by law or for benefits purposes. We will not disclose your SSN without your consent to anyone outside the company except as mandated by law or as required for essential business operations. Failure to provide an SSN may result in the withdrawal of an employment offer and/or the denial of benefits. If an employment offer is made, our payroll vendor will verify your SSN through to ensure that we are accurately reporting your wages to Federal and State agencies. The resource used to verify your SSN (i.e. SSNVS, E-Verify, etc.) is at the discretion of our payroll provider. This verification DOES NOT call into question your immigration status or your authorization to work in the United States. You will be notified in writing of any mismatch notices that cannot be resolved as a clerical error by our staff. Notification of a mismatched SSN that you receive will not have any adverse effect on your employment status, but it could impact your tax liability. Applications of candidates who are not offered employment will be destroyed in accordance to our record retention policy. I certify that this application does not constitute or imply any offer of employment with In-Home Care, Inc. Any offer of employment is subject to their hiring policies and procedures.