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Full Name

Date of Birth

Phone

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City

State/Province

Postal/ Zip Code

Are you 21 years of age or older?

Are you authorized to work In The United States?

Are you currently living in the DMV Area?

Do You Own A Car?

Do You Have A Drivers License?

Areas you are comfortable commuting to:

Distance Willing To Travel?

Desired Salary

When do you want to start?

Skills/Qualifications

A short bio about yourself for prospective employer

What skills and experience do you have that are useful for Caregiving? Feel free to be as in depth as possible.

List three words that describe your personality

CPR/First Aid Certified?

CPR/First Aid Expiration Date

CMT Certified

DDA Training

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List 3 Professional Reference

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APPLICANT STATEMENT AND AGREEMENT
Please read and initial each paragraph below. If there is anything that you do not understand, please ask.
I hereby authorize DHCS to thoroughly investigate my references, work record, education, and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to DHCS For any letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release DHCS, my former employers, and all other persons, corporations, partnerships, and associations from all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.
In the event of my employment with DHCS, I understand that I must comply with all Company rules and regulations.
If hired, I understand and agree that my employment with DHCS is at will and that neither I nor DHCS is required to continue the employment relationship for any specific term.
I further understand that DHCS or I may terminate the employment relationship at any time, with or without cause, and with or without notice.
I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.
I understand that the safety of employees is extremely important to DHCS and that DHCS is committed to ensuring a safe working environment.
I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor.
I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health.
I hereby certify that my answers are true and correct to the best of my knowledge.
I further certify that I, the undersigned applicant, have personally completed this application.
I, understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or immediate discharge if I am employed, regardless of the time elapsed before discovery.
I, understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States and that federal immigration law requires me to complete an I-9 Form in this regard.
I, understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable.

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