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CT Home Care
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Job Application

Please fill out the following form to apply for a position with Connecticut In-Home Assistance.

Name:     Social Security #:
Present Address:
City:     State:     Zip:
Home Phone:     Cell Phone:
Emergency Contact:     Phone:
Languages Spoken:
Positions Interested In:
Do you have a car available for daily use?
Do you hold a current drivers license?
Would you be willing to use your car for client errands?
Would you be willing to use your car for client transportation?
Do you have any physical impairments that would interfere with your ability to perform the activities required of your position?
If yes, please explain:
Have you ever been convicted of a crime of have criminal charges pending, excluding misdemeanors?
If yes, please explain: (a prior arrest will not necessarily be a barrier to employment)
 
PLEASE NOTE: Work schedule is based on client needs. Full-time work is not guaranteed. Most work schedules begin as part-time.
Please fill in the hours you are available to work each day:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Are you interested in 12 or 24 hour shifts?
Do you have any allergies to pets, cigarette smoke, other?
If yes, please explain:
 
EDUCATION: What is the highest grade completed?
School Name/Location:
Additional Training (check all that apply): Licensed Practical Nurse      Certified Nurse's Aide      Home Health Aide
State of Licensure: Date of Licensure/Certification:
 
EMPLOYMENT RECORD (LAST 5 YEARS, BEGIN WITH CURRENT POSITION):
Name of Employer:   Dates Employed From/To:   Position:
Name of Employer:   Dates Employed From/To:   Position:
Name of Employer:   Dates Employed From/To:   Position:
Name of Employer:   Dates Employed From/To:   Position:
Name of Employer:   Dates Employed From/To:   Position:
 
PERSONAL REFERENCES:
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
 
COPY AND PASTE YOUR RESUME OR TELL US ABOUT YOURSELF:

The information I have provided is true and complete to the best of my knowledge. In the event of employment, I understand that false or misleading information given in this application or interview may result in discharge whenever discovered. I understand, also, that I am required to abide by all rules and regulations of CT In-Home Assistance, LLC.

I understand that all employment with CT In-Home Assistance, LLC is on an at-will basis. Employees are free to resign or may be terminated at any time. Neither this application nor any other personnel forms or policies constitute and employment contract. I understand that no representative of CT In-Home Assistance, LLC other then the owner(s) has any authority to enter into any agreement contrary to the foregoing and any such agreement must be in writing.

 

Please type your name into the following box as acknowledgement of these terms:
 
CT In-Home Assistance, LLC does not discriminate on the basis of race, color, national origin, handicap, or age in admission or access to, service or employment in its programs or activities.
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Copyright © 2012 Connecticut In-Home Assistance. All rights reserved.
Connecticut In-Home Assistance
Trumbull & Hamden, CT
Phone: 855-412-CARE

Email: info@CTHomecare.com
www.cthomecare.com