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APPLICATION FOR EMPLOYMENT

Indus Home Health Care is an equal opportunity employer and does not discriminate against applicants or employees on the basis of sex, race, color, religion, national origin, ancestry or age (40 years of age and over). In addition, Indus Home Health Care does not discriminate against qualified individuals with disabilities.

PERSONAL INFORMATION
Name*  
Last
First
Middle
SOCIAL SECURITY
PRESENT ADDRESS *
STREET
CITY
STATE
ZIP
HOW LONG AT THIS ADDRESS
YEARS
HOME PHONE
ARE YOU 18 YEARS OR OLDER? Yes: No 
IN CASE OF EMERGENCY NOTIFY
NAME
PHONE
DO YOU HAVE ACCESS TO ADEQUATE TRANSPORTATION TO TRAVEL TO AND FROM WORK? Yes: No 
IF NO. EXPLAIN

ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS? YES - NO IF HIRED, PROOF OF YOUR IDENTITY AND EMPLOYMENT ELIGIBILITY IN THE UNITED STATES MUST BE ESTABLISHED BY APPROPRIATE DOCUMENTATION AT THE TIME YOU BEGIN WORK.

 
EMPLOYMENT DESIRED*
 
POSITION
DATE YOU CAN START
SALARY  DESIRED
ARE YOU EMPLOYED NOW?
YOUR PRESENT EMPLOYER?
EVER APPLIED TO THIS COMPANY BEFORE?
WHERE?
WHEN?
REASON FOR LEAVING
NAME OF LAST SUPERVISOR AT THIS COMPANY
PHONE NUMBER
 

AVAILABILITY   * ( PLEASE CHECK THE DAYS YOU ARE AVAILABLE TO WORK)

 
 MONDAY A.M P.M
 TUESDAY A.M P.M
 WEDNESDAY A.M P.M
 THURSDAY A.M P.M
 FRIDAY A.M P.M
Are you willing to work an irregular schedule,overtime and weekend when necessary?if no,please explain
 
EDUCATION/MILITARY SERVICE
 
HIGH SCHOOL
SCHOOL LEVEL
NO OF YEARS ATTENDED
DID YOU GRADUATE
COLLEGE  
SCHOOL LEVEL
DID YOU GRADUATE
TRADE BUSINESS OR CORRESPONDENCE SCHOOL  
SCHOOL LEVEL
NO OF YEARS ATTENDED
DID YOU GRADUATE
 
 

REFERENCES    (LIST NAMES OF THREE PEOPLE NOT RELATED TO YOU,WHOM YOU HAVE KNOWN AT LEAST ONE YEAR )

REFERENCE : 1 *
NAME
ADDRESS
PHONE
RELATIONSHIP
YRS.ACQUAINTED
   
REFERENCE : 2 *  
NAME
ADDRESS
PHONE
RELATIONSHIP
YRS.ACQUAINTED
   
REFERENCE : 3 *  
NAME
ADDRESS
PHONE
RELATIONSHIP
YRS.ACQUAINTED
   
 

FORMER EMPLOYER *  ( LIST EMPLOYMENT HISTORY FOR THE LAST TWO YEARS(EXPLAIN ANY GAPS IN EMPLOYMENT).USE ADDITIONAL SHEET OF PAPER IF NEEDED INFORMATION MUST BE COMPLETE)

 
NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER
PHONE
STARTING DATE
MONTH
YEAR
LEAVING DATE
MONTH
YEAR
WEEKLY STARTING SALARY
WEEKLY FINAL SALARY
JOB TITLE
MAY WE CONTACT YOUR SUPERVISOR?
NAME AND TITLE OF SUPERVISOR
DESCRIPTION OF WORK
REASON FOR LEAVING
 

FORMER EMPLOYER  * ( LIST EMPLOYMENT HISTORY FOR THE LAST TWO YEARS(EXPLAIN ANY GAPS IN EMPLOYMENT).USE ADDITIONAL SHEET OF PAPER IF NEEDED INFORMATION MUST BE COMPLETE )

 
NAME AND ADDRESS OF PRESENT OR LAST EMPLOYER
PHONE
STARTING DATE
MONTH
YEAR
LEAVING DATE
MONTH
YEAR
WEEKLY STARTING SALARY
WEEKLY FINAL SALARY
JOB TITLE
MAY WE CONTACT YOUR SUPERVISOR?
NAME AND TITLE OF SUPERVISOR
DESCRIPTION OF WORK
REASON FOR LEAVING
HAVE YOU BEEN CONVICTED OF FELONY OR MISDEMEANOR THE LAST 5 YEAR? Yes: No 
IF YES DESCRIBE
WHEN CONTACTED WHAT WILL YOUR FORMER EMPLOYER SAY WAS YOUR GREATEST
STRENGTHS
WEAKNESSES
 
CERTIFICATION AND AUTHORIZATION PLEASE REVIEW CAREFULLY

I CERTIFY THAT ALL THE FACTS CONTAINED IN THE APPLICATION ARE TRUE AND COMPLETE AND ACKNOWLEDGE THAT INDUS HOME HEALTH CARE IS RELYING ON THE ACCURACY OF THE INFORMATION PROVIDED. I AUTHORIZE INDUS HOME HEALTH CARE TO VERIFY THE ACCURACY OF THE INFORMATION PROVIDED HEREIN, AND I AUTHORIZE FORMER EMPLOYERS, EDUCATIONAL INSTITUTIONS, AND CREDIT AGENCIES TO RELEASE INFORMATION CONCERNING ME TO INDUS HOME HEALTH CARE. I ALSO AUTHORIZE INDUS HOME HEALTH CARE TO GIVE REFERENCES AND PROVIDE INFORMATION ABOUT ME IN RESPONSE TO ENQUIRES SUBSEQUENT TO MY EMPLOYMENT. IF HIRED, I UNDERSTAND AND AGREE THAT IF HIRED, MY EMPLOYMENT WILL BE FOR NO DEFINITE PERIOD AND MAY REGARDLESS OF THE DATE OF PAYMENT OF WAGES, BE TERMINATED AT ANY TIME WITHOUT PREVIOUS NOTICE AND WITH OR WITHOUT REASON BY INDUS HOME HEALTH CARE. I ALSO UNDERSTAND AND AGREE THAT NO ONE HAS THE AUTHORITY TO PROMISE ME JOB SECURITY OR CONTINUED EMPLOYMENT, EXPECT THE CEO OF THE COMPANY IN A FORMAL WRITTEN AGREEMENT SIGNED BY BOTH OF US. I ALSO UNDERSTAND THAT IF I CHOOSE TO LEAVE MY POSITION, I WILL PROVIDE AND COMPLETE A TWO-WEEK NOTICE: OTHERWISE MY FINAL PAYCHECK MAYBE DECREASE TO MINIMUM WAGE.

SIGNATURE OF APPLICANT *
DATE *
 

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