ATTENTIVE HOME CARE LLC - Employment Application Form

Sep 14, 2026

Upload by Elsa

Employment application form for ATTENTIVE HOME CARE LLC collecting candidate personal details, contact information, work authorization eligibility, and criminal history disclosure. The form captures available working hours, education and training history, and complete work history including positions, duties, salaries, and reasons for leaving. It also requests supporting statements tied to the job description, medical history questions relevant to job duties, references, and a declaration confirming accuracy. The document includes a confidential agreement requiring careful reading and signature, authorizing verification and outlining consequences for falsification.

LanguageEnglish

CategoryResumes

FormatPDF

Pages13

Reading Time5 min

AccessFree to download

Application Qualification/Job Description

Part A: Personal Information

Part B: Education and Training

Work History

Present or Most Recent Employer

Past Work History One

Past Work History Two

Part D: Supporting Statement

Part E: Medical History

Part F: References

Part G: Declaration and Confidential Agreement

ATTENTIVE HOME CARE LLC A Application Qualification/Job Description attentive home care llc APPLICATION FOR EMPLOYMENT (Please Fill Out Completely) Date of Application Social Security Number / / Print Full Name Home Phone: Mobile: Email: Address City State Zip Code Position Applied For Documents required with this application (All) Check if attached 1. Thoroughly completed employment application ( ) 2. Current Professional License (Signed), if any ( ) 3. Current CPR card/First Aid (Signed) ( ) 4. PPD/Chest X-Ray /Medical ( ) 5. Employment Eligibility Verification (Form I-9) ( ) 6. Two employment reference forms or letter (phone \# included) ( ) 7. One personal reference form or letter (phone \# included) ( ) 8. Driver’s License/ State Issue ID card (Signed) ( ) 9. Copy of Social Security Card (Bring original signed copy to interview) ( ) 10. One year of experience working in the field ( ) 11. Background Check (a must) ( ) 12. Any other information you havefor employment ( ) If you do not have all the documents above, please tell us when it will be available: EMPLOYMENT APPLICATION FORM PART A: PERSONAL INFORMATION | Title: Mr. /Miss /Mrs.
Other ( Please specify) | | | | | First Name: | | | Last Name: | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Home Address: | | | | | Correspondence Address (If different: | | | | | | | Home Telephone: Work Telephone:
May we contact you at work? Yes/ No | | | | | | | | | | | | Are you a citizen of the United States? Yes/ No
If no, are you eligible to work in the United States? Yes/ No
If you are under age 18, do you have an employment/age certificate? Yes No | | | | | | | | | | | | Have you ever been convicted of a misdemeanor or felony? Yes/ No
If yes, please explain the circumstances of the conviction. | | | | | | | | | | | | | | AVAILABLE HOURS (in HH:MM format) | | | | | | | | | | | | SUNDAY | MONDAY | TUESDAY | | WEDNESDAY | THURSDAY | FRIDAY | SATURDAY | | | | FROM: | | | | | | | | | | | | TO: | | | | | | | | | | PART B: EDUCATION AND TRAINING | High School Name and Address | Dates Attended: | Diploma
Received?
Yes No | Area of Study | | --- | --- | --- | --- | | Colleges/ Training Schools | Dates Attended: | Diploma
Received?
Yes No | Area of Study | | Professional trainings/ qualifications with dates and levels obtained | | | | PART PRESENT PAST WORK HISTORY | Present or mostrecent employer and address: | Dates(month/ year) | Position Held and Duties: | Reason for leaving | | --- | --- | --- | --- | | Starting Salary:
Ending Salary: | | May we contact this employer? If no, please indicate reason. | Yes/ No | | Give details of your work history with the most recent listed first: ONE | | | | | --- | --- | --- | --- | | Employer and address: | Dates (month/ year) | Position Held and Duties: | Reason for leaving | | Starting Salary:
Ending Salary: | | May we contact this employer? If no, please indicate reason. | Yes/ No | | Give details of your work history with the most recent listed first: TWO | | | | | --- | --- | --- | --- | | Employer and address: | Dates (month/ year) | Position Held and Duties: | Reason for leaving | | Starting Salary:
Ending Salary: | | May we contact this employer? If no, please indicate reason. | Yes/ No | C: AND WORK HISTORY WORK HISTORY | PART D: SUPPORTING STATEMENT | | --- | | Please indicate all relevant experience, skills and work history that relate to the job description of which you have applied. Please print clearly. All illegible entries will not be considered.
(attach additional sheets if necessary) | | PART E: MEDICAL HISTORY | | | --- | --- | | What absences due to illness have you had from work for the last two years? | | | Do you have any illness that will present you from performing the

FAQs

What information does the employment application collect from the applicant?

It collects personal information, contact details, citizenship/work authorization eligibility, conviction history disclosure, available hours, education and training, and employment work history.

What supporting documents are required with the application?

The form lists required documents such as a completed application, professional license (if any), CPR/First Aid card, PPD/Chest X-Ray/Medical, Form I-9 employment eligibility verification, employment references, identification cards, Social Security card copy, one year of experience proof, and a background check.

What does the declaration and confidential agreement require the applicant to confirm?

The applicant must certify the information is true and complete, agree to confidentiality regarding the company’s proprietary information, authorize ATTENTIVE HOME CARE LLC to verify application sources, and understand falsification can lead to withdrawal or immediate discharge.

Sep 14, 2026

Upload by Elsa