Skip to content
Jewelsblessingshomecare@gmail.com
(317) 223-3323
(317) 978-2722
Facebook-f
Instagram
Linkedin-in
Google
Quick Inquiry
Schedule Appointment
Home
About
Services
Personal Care
Homemaking Services
Transportation & Errands
Companion Care
Memory Care
Overnight Care
Veteran Care
Blog
Service Areas
Careers
Contact
Home
About
Services
Personal Care
Homemaking Services
Transportation & Errands
Companion Care
Memory Care
Overnight Care
Veteran Care
Blog
Service Areas
Careers
Contact
Home
About
Services
Personal Care
Homemaking Services
Transportation & Errands
Companion Care
Memory Care
Overnight Care
Veteran Care
Blog
Service Areas
Careers
Contact
Home
About
Services
Personal Care
Homemaking Services
Transportation & Errands
Companion Care
Memory Care
Overnight Care
Veteran Care
Blog
Service Areas
Careers
Contact
Schedule Appointment
Submit Job Application Online
"
*
" indicates required fields
Step
1
of
6
16%
Employment Application
All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
Personal Information
First Name
*
Last Name
*
Date
*
MM slash DD slash YYYY
Street Address
*
Home Phone
*
City, State, Zip Code
*
Business Phone
*
Emergency contact (person not living with you)
*
Have you ever applied for employment with this Agency?
*
Yes
No
How many hours a week are you available for work?
*
Are you legally eligible for employment in the United States?
*
Yes
No
How did you learn of our organization?
*
Online Ad
Agency employee
Other
Are you willing to work
Evenings?
Weekends?
Position applying for
*
Education
College
School Name
Location of School
Course of Study
Degree/Dip
Vo-Tech or Trade
School Name
Location of School
Course of Study
Degree/Dip
High School
School Name
*
Location of School
*
Course of Study
*
Degree/Dip
*
Other
School Name
Location of School
Course of Study
Degree/Dip
Employment
List the last five years employment history, starting with the most recent employer.
1. Company Name
*
Telephone
*
Address
*
City, State, Zip Code
Dates of Employment
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Starting Pay
*
Job Title and describe your work
*
Reason for leaving
*
2. Company Name
*
Telephone
*
Address
*
City, State, Zip Code
Dates of Employment
From
*
MM slash DD slash YYYY
To
*
MM slash DD slash YYYY
Starting Pay
*
Job Title and describe your work
*
Reason for leaving
*
3. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
4. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
5. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
Was your last name different from your present name during the above listed jobs?
*
Yes
No
If yes, what was your name?
*
Are you currently employed?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Professional References
Persons who can furnish information about job performance
1. Name
*
Telephone
*
Email
*
Address
*
2. Name
*
Telephone
*
Email
*
Address
*
3. Name
Telephone
Email
Address
General
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
*
Yes
No
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full
*
Are you capable of performing the job set forth in the job description?
*
Yes
No
If you answered No, which job requirement can you not meet?
*
Credentials/specialized skills & qualifications/equipment operated
List all states in which licensed giving registration and expiration date. Summarize special jobrelated skills and qualification acquired from employment or other experience.
*
Please read all statements below before signing this application
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 complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.
This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.
I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.
Date
*
MM slash DD slash YYYY
Signature
*
Employee Emergency Contact Information
Employee Name
*
Current Address
*
Home Phone
*
Cell Phone
*
*In case of emergency, please contact:
Name
*
Phone
*
Relationship
*
Address
*
*Please notify this Agency immediately if any of the emergency contact information changes.
Tb Targeted Medical Questionnaire And Risk Form
Employee Printed Name
*
1. Have you ever had a positive TB skin test or history of TB infection?
*
Yes
No
If the answer is YES, please answer the following:
2. Have you ever had the BCG vaccine?
*
Yes
No
3. Do you have prolonged or recurrent fever?
*
Yes
No
4. Have you recently lost weight?
*
Yes
No
5. Do you have a chronic cough?
*
Yes
No
6. Do you cough up blood?
*
Yes
No
7. Do you have sweating at night?
*
Yes
No
8. Do you have any of the following risk factors
*
a. Silicosis (lung disease)
b. Gastrectomy
c. Intestinal Bypass
d. Weight 10% or more below ideal body weight
e. Chronic Renal Disease
f. Diabetes Mellitus
g. Prolonged high-dose corticosteroid therapy or other Immunosuppressive therapy
h. Hematologic Disorder i.e. leukemia or lymphoma
i. Exposure to HIV or AIDS
j. Other malignancies
Baseline Individual TB Risk Assessment
Answer “Yes” or “No”. Employee should be considered at risk for TB if any of the following statements are marked “Yes”.
Temporary or permanent residence of > 1 month in a country with a high TB rate (any country other than the U.S., Canada, Australia, New Zealand, and those in Northern or Western Europe)
*
Current or planned immunosuppression, including HIV infection, organ transplant recipient, treatment with a TNF alpha antagonist, chronic steroids, or other immunosuppressive medication.
*
Close contact with someone who has had infectious TB disease since the last TB test
*
Employee Signature
*
Date
*
MM slash DD slash YYYY
Attach Files: Identification Card, Updated T.B Result (within 6 months), First Aid /CPR certificate, and Social Security card
*
Drop files here or
Select files
Max. file size: 512 MB.
Quick Inquiry
Instagram
This field is for validation purposes and should be left unchanged.
Name
(Required)
Phone
(Required)
Email
(Required)
Message Us:
Schedule Appointment
URL
This field is for validation purposes and should be left unchanged.
Name
(Required)
Phone
(Required)
Email
(Required)
Best Time to call
Morning
Afternoon
Evening
Message Us:
