* = Required Information
Applicant Information
Full Name: *
Last Name
First Name
Middle Name		 Date:
Address:
Street Address		 Apartment/Unit#:
 
City
State
Zip Code
Phone: E-mail Address:
Date Available: Social Security No: Desired Salary: $
Position Applied For:
Are you citizen of the United States? YesNo
Have you ever worked in this company? YesNo
Have you ever been convicted of a felony? YesNo
Education
High School Address
From To Did you graduate? YesNo Degree
College Address
From To Did you graduate? YesNo Degree
Other Address
From To Did you graduate? YesNo Degree
References
Please list two professional references and one character reference.
Full Name Relationship
Company
Address
Phone
Full Name Relationship
Company
Address
Phone
Full Name Relationship
Company
Address
Phone
A PLUS HOME HEALTH CARE AGENCY, LLC. requires that all employees, contractors, representatives or other associates recognize our proprietary ownership of documents and information applicable to our business. Such information includes, but is not limited to, trade secrets, sales, cost, pricing, marketing ideas, development, research, records, technical data, information on computer disks or printouts, programs, processes, plans, list of clients, financial Information, forecasts, client records and any other information which derives Independent economic value from not being generally known to other persons who cannot obtain economic from its disclosure or use. All Such employees and contracting parties, by their signatures on this application form, agree not to disclose such information to competitors or use such information to compete with A PLUS HOME HEALTH CARE AGENCY, LLC. for a period of two years after termination of services with A PLUS HOME HEALTH CARE AGENCY, LLC.. We will take legal action against any and all individuals who violate this confidentiality, non-disclosure and non-compete agreement.
Previous Employment
Company Phone
Address Supervisor
Company Phone
Address Supervisor
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? YesNo
Job Title Starting Salary $ Ending Salary $
Responsibilities
From To Reason for leaving
May we contact your previous supervisor for a reference? YesNo
Job Title Starting Salary $ Ending Salary $
Responsibilities
From To Reason for leaving
May we contact your previous supervisor for a reference? YesNo
Military Service
Branch From To
Rank at Discharge Type of Discharge
If other than honorable, explain
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Applicants Name * Date