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Yes 􀀀 No 􀀀\u003Cbr>Have you lived in PA for the last 2 years consecutively? Yes 􀀀 No 􀀀\u003Cbr>Social Security \\# - - Are you authorized to work in the U.S.? Yes 􀀀 No 􀀀\u003Cbr>(Employment is subject to verification in the U.S) |\n| --- |\n| Have you ever applied here before?   Yes 􀀀 No 􀀀\u003Cbr>If yes, when?  \u003Cbr>Were you ever employed here?   Yes 􀀀 No 􀀀\u003Cbr>If yes, when?  \u003Cbr>Have you ever been convicted of any law violation (except for minor traffic violations)?   Yes 􀀀 No 􀀀 If yes, give details:  \u003Cbr>(A “Yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will also be considered. )\u003Cbr>Do you have a valid driver’s license?   Yes 􀀀 No 􀀀\u003Cbr>Driver’s License Number  State of License:  Class of License   Have you had your driver’s license suspended or revoked in the last 3 years?   Yes 􀀀 No 􀀀\u003Cbr>If yes, give details:   |\n\n\n|  Other Licenses/ Certification\u003Cbr>CNA License   Yes 􀀀 No 􀀀 HHA certification   Yes 􀀀 No 􀀀 CPR   Yes 􀀀 No 􀀀 BLS   Yes 􀀀 No 􀀀\u003Cbr>Medical and clearances \u003Cbr>Child abuse clearance   Yes 􀀀 No 􀀀\u003Cbr>Federal background check FBI ………………………Yes 􀀀 No 􀀀 Background ………………………………….…………Yes 􀀀 No 􀀀 Physical ………………………………………….………Yes 􀀀 No 􀀀 TB/ PPD   Yes 􀀀 No 􀀀\u003Cbr>Chest X-ray   Yes 􀀀 No 􀀀 |\n| --- |\n| \\# of Years Diploma/ Subjects\u003Cbr>Completed Degree/\u003Cbr>Studied Certificate\u003Cbr>LIST NAME AND ADDRESS OF SCHOOLS\u003Cbr>High School or GED:        \u003Cbr>College or University:        \u003Cbr>Vocational or Technical:        \u003Cbr>What skills or additional training do you have that are related to the job for which you are applying?  \u003Cbr>What machines or equipment can you operate that are related to the job for which you are applying?   |\n\n\n| List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service. |  |  |\n| --- | --- | --- |\n| NAME OF EMPLOYER | JOB TITLE AND DUTIES |  |\n| ADDRESS | DATES OF EMPLOYMENT: FROM TO |  |\n| CITY, STATE, ZIP CODE | PAY: START $ FINAL $ |  |\n| SUPERVISOR | TELEPHONE | REASON FOR LEAVING |\n| NAME OF EMPLOYER | JOB TITLE AND DUTIES |  |\n| ADDRESS | DATES OF EMPLOYMENT: FROM TO |  |\n| CITY, STATE, ZIP CODE | PAY: START $ FINAL $ |  |\n| SUPERVISOR | TELEPHONE | REASON FOR LEAVING |\n| NAME OF EMPLOYER | JOB TITLE AND DUTIES |  |\n| ADDRESS | DATES OF EMPLOYMENT: FROM TO |  |\n| CITY, STATE, ZIP CODE | PAY: START $ FINAL $ |  |\n| SUPERVISOR | TELEPHONE | REASON FOR LEAVING |\n| NAME OF EMPLOYER | JOB TITLE AND DUTIES |  |\n| ADDRESS | DATES OF EMPLOYMENT: FROM TO |  |\n| CITY, STATE, ZIP CODE | PAY: START $ FINAL $ |  |\n| SUPERVISOR | TELEPHONE | REASON FOR LEAVING |\n| Are you presently employed?   Yes 􀀀 No 􀀀 If yes, may we contact your present employer?   Yes 􀀀 No 􀀀 Have you ever been fired from a job or asked to resign?   Yes 􀀀 No 􀀀 If yes, please explain: \u003Cbr>Give two professional references, not relatives.\u003Cbr>Name Address Phone\u003Cbr>  () -    () -  |  |  |\n| PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING\u003Cbr>Homecare Precision. Provides equal employment opportunities (EEO) to all employees and applicants for employment and is committed to providing a workplace free from harassment or discrimination. All employment without regard to race, color, sex, age, handicap, marital status, sex orientation religions , national origin, disability, pregnancy, age, or military or veteran status in accordance with federal law. In addition, Homecare Precision complies with applicable state and local laws governing non-discrimination in employment in every jurisdiction in which it maintains facilities. Homecare Precision also provides reasonable accommodation to qualified individuals with disabilities in acco","cbCail4Oujea30uG","https://ap.wps.com/l/cbCail4Oujea30uG","pdf",410423,24,"English","# Applicant Information\n## Availability and Work Eligibility\n# License, Certification, and Clearances\n## Education and Related Skills\n# Employment History and References\n## Declarations and Signatures","[{\"question\":\"What information is required for the applicant’s identity and contact details?\",\"answer\":\"The form asks for last name, first name, telephone number, and address including city, state, and zip code, along with the job applied for and today’s date.\"},{\"question\":\"What eligibility questions are included in the form?\",\"answer\":\"It includes work authorization in the U.S., age (18 or older), whether the applicant has lived in PA for the last two years consecutively, and whether Social Security information is provided.\"},{\"question\":\"What employment history and reference information must the applicant provide?\",\"answer\":\"Applicants must list employers in consecutive order with job duties, addresses, employment dates, pay, supervisor contact, and reasons for leaving, and provide two professional references that are not relatives.\"}]","Employment Application Form - Homecare Precision - Job Application | PDF"]