* = Required Information

DATE: December 12, 2018
Name
Last * First * Middle Maiden
Present address
Number Street City State Zip
How long at this address? Social Security No.
Telephone Cell phone
If under 21, please list age
Do you now, or have you lived outside the state of Indiana in the last 2 years?
Position applied for (1) and salary desired (2)
Days/hours available to work
No Pref Thur
Mon      Fri    
Tue       Sat  
Wed     Sun  
All Days     Hrs  
How many hours can you work weekly?
Can you work nights/weekends?           
Employment desired     
FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME
When available for work? Email Address
TYPE OF SCHOOL NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YEARS COMPLETED MAJOR & DEGREE
High School
College
Bus. or Trade School
Professional School
HAVE YOU EVER BEEN CONVICTED OF A CRIME?    YesNo
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
DO YOU HAVE A DRIVER'S LICENSE?    YesNo
What is your means of transportation to work?
Driver's license number State of issue
Type of License
Operator Commercial (CDL) Chauffeur
Expiration date
Have you had any accidents during the past three years?                Yes No
How many?      
Have you had any moving violations during the past three years?    Yes No
How many?      
EMERGENCY INFORMATION
Color, make, & model of car you will be driving most to work.
License plate number
Emergency contact:     Phone:
Emergency contact:     Phone:
Please list two references other than relatives or previous employers.
Name        Name      
Position    Position  
Company Company
Address      Address
Day-time telephone Day-time telephone
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.
What cities are you available to work in? Check all that apply
Brookville Versailles Cross Plains Batesville
Rising Sun
Are you willing to start with one client and build your clientele?YesNo
Do you have past homemaking experience?YesNo
Have you ever performed attendant care services (personal care, bathing, etc)?YesNo
If not, would you be willing to learn how to perform these services?YesNo
***ALL PROSPECTIVE EMPLOYEES MUST PASS A DRUG SCREEN BEFORE HIRING****
MILITARY
HAVE YOU EVER BEEN IN THE ARMED FORCES?YesNo
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?YesNo
Specialty Date Entered Discharge Date
Work
Experience
Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Name of employer
Address

City

State

Zip Code
Name of last supervisor Employment dates Pay or salary

From

To

Start

Final
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.


Name of employer
Address

City

State

Zip Code
Name of last supervisor Employment dates Pay or salary

From

To

Start

Final
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.


Name of employer
Address

City

State

Zip Code
Name of last supervisor Employment dates Pay or salary

From

To

Start

Final
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.


Name of employer
Address

City

State

Zip Code
Name of last supervisor Employment dates Pay or salary

From

To

Start

Final
Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer?YesNo
Did you complete this application yourself?    Yes No
If not, who did?    

Security Code *