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: COMPANION HOMEMAKER PERSONAL CARE ASSISTANT

Do you have a car available for daily use? Yes No

Do you hold a current drivers license? Yes No

Would you be willing to use your car for client errands? Yes No

Would you be willing to use your car for client transportation? Yes No

Do you have any physical impairments that would interfere with your ability to perform the activities required of your position? Yes No

If yes, please explain:

Have you ever been convicted of a crime of have criminal charges pending, excluding misdemeanors? Yes No

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? 12 hour shifts 24 hour shifts

Do you have any allergies to pets, cigarette smoke, other? Yes No

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:

PERSONAL REFERENCES:

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.

Connecticut In-Home Assistance
Trumbull, CT 06611
Phone: 855-412-CARE
Email: info@CTHomecare.com
www.cthomecare.com