* = Required Information

Application Packet

All forms and requirements must be properly accomplished and completed

EXPIRATION DATE
Application Form
Photocopy of Current Drivers License
Photocopy of cpr and first aid certificate
Copy of social security number
Dmv registration
Copy of current car insurance policy
Copy of tuberculosis (tb) test
Copy of physical medical test
Copy of fingerprinting/doj clearance
Independent contractor’s agreement
Background check of 3 referrals

General Information

Full-time Part-time Temporary Seasonal
Yes No
Yes No
Yes No
Yes No

Answering yes does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied will be considered.

Employment Record

BEGIN WITH YOUR MOST RECENT EMPLOYER. LIST ALL JOBS YOU HAVE HELD WITHIN THE PAST 10 YEARS.



Yes No



Yes No



Yes No



Yes No

References

PLEASE INCLUDE A MIX OF DIRECT REPORTS, PEERS AND IMMEDIATE SUPERVISORS. MINIMUM THREE (3).

Education

BEGIN WITH THE MOST RECENT WORK TOWARD A DEGREE OR DIPLOMA





Emergency Contact Information

AGREEMENT

I HAVE READ THIS JOB APPLICATION CAREFULLY. I SWEAR UNDER PENALTY OF PERJURY THAT ALL THE INFORMATION PROVIDED BY ME ON THIS JOB APPLICATION AND ON MY ACCOMPANYING RESUME IS TRUE. I HEREBY AUTHORIZE INVESTIGATION OF ALL STATEMENTS MADE BY ME IN THIS APPLICATION. I AUTHORIZE REFERENCES, SCHOOLS, FORMER EMPLOYEES AND OTHERS, EXCEPT AS NOTED, TO BE QUESTIONED IN CONNECTION WITH THIS APPLICATION, AND I GRANT THEM PERMISSION TO PROVIDE PEARL IN-HOME CARE AND SERVICES, INC. WITH ANY AND ALL INFORMATION CONCERNING MY EMPLOYMENT AND ANY OTHER PERTINENT INFORMATION THAT THEY MAY HAVE. FURTHER, I RELEASE ALL PARTIES AND PERSONS FROM ANY AND ALL LIABILITY FOR ANY DAMAGES THAT MAY RESULT FROM FURNISHING INFORMATION TO OR EXCHANGING INFORMATION WITH, THE PEARL IN-HOME CARE AND SERVICES, INC. OR ITS AGENTS. I UNDERSTAND THAT ANY MISREPRESENTATION, FALSIFICATION, OR MATERIAL OMISSION OF INFORMATION ON THIS APPLICATION MAY RESULT IN MY FAILURE TO RECEIVE AN OFFER OR, IF I AM HIRED, MY DISMISSAL FROM EMPLOYMENT.



I UNDERSTAND THAT, IF HIRED, I MUST PROVE THAT I AM LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES.



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