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					EMPLOYMENT APPLICATION
INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the
person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.
        1. Please read "APPLICANT NOTE" BELOW.
        2. Complete all sides of this form.
        3. If more space is needed to complete any question, use comments section on the back.
        4. Print clearly. Incomplete or illegible applications may not be processed.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment. This is not an
employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the
interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating
employment. All qualified applicants will receive consideration without discrimination because of gender, marital status, pregnancy,
religion, race, age, creed, national origin, presence of disabilities, sexual orientation, genetic screening or testing information, refusal
to submit to a genetic test, ancestry, AIDS or HIV status, and on any other status protected by law. Additional testing for the
presence of illegal drugs in your body may be required prior to employment.

TODAY'S DATE: ___________________________                               SOCIAL SECURITY NUMBER: _________-_________-__________

EMAIL:____________________________________                              Date of Availability:________________________________________

NAME: ____________________________________________________________________________________________________
              Last                                     First                           Middle                             Maiden

CURRENT ADDRESS: _______________________________________________________________________________________
                                  No.                          Street                   City                      State        Zip Code

PREVIOUS ADDRESS: _______________________________________________________________________________________
                                  No.                          Street                   City                      State        Zip Code


HOME PHONE#: (______)_____________________________ WORK PHONE#: (______)______________________________


MOBILE PHONE#: (______)_________________________ ALTERNATE PHONE#:(_____)____________________________


EMERGENCY CONTACT: ____________________________________________________________________________________
                                          Name                                                  Phone #                   Relationship

VALID DRIVER’S LICENSE#: _______________________________ STATE ISSUED: ___________ EXP. DATE: ___________

MAKE & YEAR OF VEHICLE: __________________________________

AUTO INSURANCE COMPANY: ________________________________________ POLICY #: ____________________________

AUTO INSURANCE AGENT: ___________________________________________ PHONE #:(_______)____________________

How did you hear about Home Instead Senior Care? ________________________________________________________________

Why are you interested in employment with Home Instead Senior Care? _________________________________________________

__________________________________________________________________________________________

                                                                                                                                               1
AVAILABILITY:
Please indicate the type(s) of work that you would prefer:
____Full-Time     ____Part-Time      ____Days      ____Evenings     ____ Overnights     ____Live-In

Approximately how many hours per week do you wish to work? ________             When are you available to begin work? _____________

Would you accept long-term assignments? ___ Yes        ___ No     Would you accept short-term assignments? ___ Yes                    No

Please indicate the days and times that you are available for work:
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               S2 i
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Please rank the following services, in order of preference that you are willing to provide. (“1” being the most preferable.)
___Companionship           ___Meal Preparation         ___Walking\Standing Assistance         ___Dressing Assistance
___Laundry                 ___Transportation           ___Running Errands                      ___Housecleaning (___Heavy ___Light)

Do you have any reservations about providing service to a client with a pet(s)? ___ No ___ Yes ( ___ Cats ___ Dogs ___Other)

Would it bother you to provide service to a client that smokes? ___ No      ___ Yes

Please rank the following areas of the city, in order of preference, in which you are able to work (#1 being the most preferable.):
____ Downtown       ____ Midtown      ____ North     ____ South     ____ East    ____ West     ____Outside City Limits
Do you speak languages other than English (please list) and do you have special talents we should be aware of (knitting, arts and crafts
and etc.)?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________


EDUCATION:
Please circle highest grade completed:
Grade School:     6 7 8             High School:       9 10 11 12        College:     13 14 15 16 16+
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                                                                                                                                       2
SECURITY:
As a condition of employment all employees must be “Bondable”.
List states and counties of residence for the past seven years: __________________________________________________________
____________________________________________________________________________________________________________
____Yes ____No Have you had any moving traffic violations? Please describe: _________________________________________
____Yes ____No Have you used any names or Social Security Numbers other than those on this application? If so, list on back.
____Yes ____No Have you been arrested for a felony and/or misdemeanor? If so, please describe below.

___INCIDENT                                                      CITY/STATE                          CHARGE____________
1___________________________________________________________________________________________________________
2___________________________________________________________________________________________________________



JOB RELATED SKILLS:
NOTE: Do not fill out any part of this section if you believe it to be non-job related.
Describe any training you have had that applies to service and/or care for the elderly.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Describe any work history applicable to Elderly Service and Care.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What do you like (or think you would like) about working with older adults?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What do you like (or think you would like) least about working with older adults?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________




PERSONAL REFERENCES (Do not include relatives):
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                                            d es
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                                                                :
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6)                                                              W:
                                                                :
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                                                                                                                           3
EMPLOYMENT REFERENCES:
Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact
previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER
Are you currently working for this employer? ___ Yes      ____ No     If yes, may we contact? ___Yes        ____ No
____________________________________    _________________________________      _______ ( _____ )____________________________
 Company Name                             City                                  State    Phone Number

From ________________ To________________ _______________________________ ______________________________________________
Dates Employed                            Job Title                         Supervisor's Name

________________________________________________________________________________________________________________________
Duties

__________________ Per _______________________ ___________________________________________________________________________
Salary                 (Hour, Week, Month)     Reason For Leaving

SECOND MOST RECENT EMPLOYER
____________________________________   ___________________________________ _______ ( _____ )____________________________
Company Name                              City                              State    Phone Number

From ______________ To_________________ ____________________________ ___________________________________________________
Dates Employed                           Job Title                    Supervisor's Name

________________________________________________________________________________________________________________________
Duties

__________________ Per _______________________ ___________________________________________________________________________
Salary                 (Hour, Week, Month)     Reason For Leaving

THIRD MOST RECENT EMPLOYER
____________________________________________   _____________________________     _______ ( _____ )____________________________
Company Name                                    City                               State      Phone Number

From ______________ To_________________ ____________________________ ___________________________________________________
Dates Employed                           Job Title                     Supervisor's Name

________________________________________________________________________________________________________________________
Duties

__________________ Per _______________________ ___________________________________________________________________________
Salary                 (Hour, Week, Month)     Reason For Leaving




FOURTH MOST RECENT EMPLOYER
____________________________________   ___________________________________ _______ ( _____ )____________________________
Company Name                              City                              State    Phone Number

From ______________ To_________________ ____________________________ ___________________________________________________
Dates Employed                           Job Title                    Supervisor's Name

________________________________________________________________________________________________________________________
Duties

__________________ Per _______________________ ___________________________________________________________________________
Salary                 (Hour, Week, Month)     Reason For Leaving




                                                                                                                                        4
FIFTH MOST RECENT EMPLOYER
____________________________________________              _____________________________           _______ ( _____ )____________________________
Company Name                                               City                                     State      Phone Number

From ______________ To_________________ ____________________________ ___________________________________________________
Dates Employed                           Job Title                     Supervisor's Name

________________________________________________________________________________________________________________________
Duties

__________________ Per _______________________ ___________________________________________________________________________
Salary                 (Hour, Week, Month)     Reason For Leaving




SIXTH MOST RECENT EMPLOYER
____________________________________________              _____________________________           _______ ( _____ )____________________________
Company Name                                               City                                     State      Phone Number

From ______________ To_________________ ____________________________ ___________________________________________________
Dates Employed                           Job Title                     Supervisor's Name

________________________________________________________________________________________________________________________
Duties

__________________ Per _______________________ ___________________________________________________________________________
Salary                 (Hour, Week, Month)     Reason For Leaving




COMMENTS:_____________________________________________________________________________
        ______________________________________________________________________________
        ______________________________________________________________________________


CERTIFICATION AND RELEASE:                                    I certify that I have read and understand the applicant note on page one of this form and that the answers
given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false
information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my
employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal
history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my
background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this
information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug
testing to detect the use of illegal drugs prior to and during employment.


 ____________________________________________________________________________________________________________________________________
                       SIGNATURE                                                                          DATE




                                                                                                                                                                           5
                         CAREGIVER JOB DESCRIPTION
As a CAREGiver, you provide a variety of non-medical services that allow seniors to remain in their homes.
These services generally fall under three categories:
       Companionship
       Home Helper
       Personal Care

    Companionship

 Companionship services are those that stimulate, encourage and assist an individual.
 The primary responsibilities of Companionship services include the following:
 Providing companionship and conversation
 Providing stabilization and assistance with walking.
 Preparing meals and cleaning up meal-related items.
 Providing medication reminders and appointment reminders


      Home Helper

Home Helper services generally involve light housekeeping, errands or incidental transportation.
The primary responsibilities of Home Helper services include the following:
Performing light housekeeping tasks (dusting, vacuuming, making beds, changing linens, cleaning
 bathrooms, kitchens, etc.)
Washing and ironing laundry
Running errands
Accompanying clients to appointments



      Personal Care

Personal Care services are personal in nature and often include assistance with activities of daily living.
The primary responsibilities of Personal Care services include the following:
Assisting with bathing
Assisting with grooming
Assisting with dressing
 Assisting with toileting and incontinence issues


Secondary Responsibilities
Secondary responsibilities include the following:
Contributing to a positive living environment to enhance a client’s quality of life
Performing other reasonable duties as assigned
Reporting hours according to office policy
Reporting any significant changes in a client’s needs or living conditions
Regularly communicating with supervisor and office staff

 Essential Qualifications
An individual must posses the minimum education, experience and skills to perform the primary and secondary responsibilities the job
requires.


                                                                                                                                  6
Additional qualifications include:
Ability to lift, push or pull 50 pounds
Ability to bend, twist, stoop, kneel and reach
Ability to withstand exposure to dust, mold, mildew and cleaning solutions
Ability to treat and care for clients and their property with dignity and respect
Ability to adapt to various living environments and locations
Ability to communicate with clients in a friendly and congenial manner

Special Qualifications
Ability to drive or take public transportation to client locations

Potential Qualifications
The CAREGiver position may require you to run errands and provide incidental transportation for a client using your vehicle or
client’s vehicle.

Potential Schedules
The CAREGiver position provides opportunities for a variety of shifts, including overnight.
_____________________________________________________________________________________

This document describes the general nature and level of work for the position. It is not a comprehensive list of its responsibilities,
duties, skills, efforts and conditions. Your employer reserves the right to modify the description in the future with or without notice.
The responsibilities for this position are subject to possible modification to reasonably accommodate individuals with disabilities.

Your employer is _________________________ (d.b.a. an independently owned and operated Home Instead Senior Care franchise).
Your employer is not Home Instead Senior Care. This job description does not create an employment contract, nor imply it.
Employment with your employer remains at will.

_____________________________________________________________________________________

I have read and thoroughly understand the duties of the CAREGiver position.



_______________________________________                 _______                 ______________________
Employee Signature                                                                     Date



_______________________________________                 _______                 ______________________
Supervisor                                                                             Date




                             Each Home Instead Senior Care franchise office is independently owned and operated.




                                                                                                                                           7
                             Home Instead Senior Care Pay Chart


Home Instead Services                                               Pay

Companionship/Home Helper/Personal Care                             $9.00/Hour

1 Hour Service                                                      $11-14/Hour

Sleep-Over/12 Hour Shift                                            $60-70/Shift

12 Hour Day Shift                                                   $96/Shift

24 Hour Care                                                        $130-150/24 Hours



Pay rates may be adjusted depending on the clients request for services or needs. Pay periods are from the 1st to
the 15th of the month and the 16th to the last day of the month. Pay checks can be picked up on the 10th and the
25th of the month depending if the pay day falls on the weekend. Please call if you wish to pick up your pay
check otherwise they will be mailed out.

Effective Date: December 2010


Signature:     ________________________________             Date: _________________

Printed Name: ________________________________




                                                                                                                8
                                  RELEASE AUTHORIZATION

Name: ________________________________           _____________________       ___________
      Last                                       First                       Middle Initial

Maiden/Previous Name(s): ______________________________________________________

Home Address: _______________________________________________________________
______________________________________           ____________________        ___________
City                                             State                       Zip Code

Social Security Number: _____________________ Date of Birth: ________________________

Driver’s License Number: ____________________ Issuing State: ________


       Authorization to Secure Consumer Investigative Report
I authorize ________________________________(Employer), d.b.a. an independently owned and
operated Home Instead Senior Care franchise, to make whatever inquiries it may deem necessary in
connection with my course of employment. As part of such inquiries, Employer has my permission to
contact persons who may have information regarding my suitability for employment and to secure
consumer reports (including investigative consumer reports).

I authorize and instruct any person or agency contacted to participate or conduct inquiries at its
request, to compile information, and to furnish any information obtained as a result of such inquiries.

I further authorize Employer, in its sole discretion, to furnish copies of this authorization and my
application to any person and/or consumer-reporting agency in connection with above purposes.

Disclosure Statement
Information contained in reports obtained by Employer in accordance with above authorization may
include information pertaining to your character, general reputation, police record, personal
characteristics, and mode of living. You have the right to request that Employer completely and
accurately disclose to you the nature and scope of all investigations requested. Such a request must
be made in writing within a reasonable period of time after your application for employment is
received.



I hereby acknowledge that I have read and understand the above disclosure statement.


______________________________________           _____________
Signature                                        Date




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