Employment Application

Note to Applicant:

This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Innovation Healthcare Solutions Enterprise Inc. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment

Personal Information

Today's Date:

Positions Applied for:

Positions

Name

Current Address

Home Phone Number

Previous Address

Cell Phone Number

Work Phone Number

Alternate Phone Number

Emergency Contacts:

Valid Driving License #

State Issued

Expiration Date

Vehicle Make and Model

Year of Model

Auto Insurance Co

Policy Number

Expiration Date

Have You Ever Applied Here before:

Have You Ever Worked Here before:

How did you hear about our Innovation Healthcare Solutions Enterprise Inc.?

Have you been given a copy of the job description for the position for which you have applied to review?

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Why are you interested in employment with us?

Due to the nature of the business, no guarantee can be made as to the schedule or the number of hours worked. What date are you available to begin work?

Please complete all areas of availability:

Monday 

Tuesday

Wednesday

Friday

AVAILABILITY:

Thursday

Sunday

Saturday

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

PREFERENCES:
Please indicate all areas of the counties in which you are willing to work:
Please indicate the types of services which you are willing to provide:

Are you willing to service a client with a pet?

If yes, which ones

Are you willing to provide service to a client that smokes?

JOB RELATED SKILLS:

Describe any training or life skills you have that apply to caring for a senior

Describe any work history you have that would apply to caring for a senior:

What do you like (or think you would like) most about caring for patients?

 What do you like (or think you would like) least about working with older adults?

What personal rewards do you get from working in healthcare?

EDUCATIONAL

Graduate

High School

Technical School

College / University

**For employment our minimum education requirement is either a GED or High School diploma*

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER

Are you currently working for this employer?
If yes, may we contact?
MOST RECENT EMPLOYER

Company Name

Company Address

Reference Phone Number

Dates Employed from ___ to ____

Supervisor's Name

Job Title

Reason for leaving

Job Duties

Salary

Hourly, Weekly, or Monthly

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SECOND MOST RECENT EMPLOYER

Company Name

Company Address

Reference Phone Number

Dates Employed from ___ to ____

Supervisor's Name

Job Title

Reason for leaving

Job Duties

Salary

Hourly, Weekly, or Monthly

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THIRD MOST RECENT EMPLOYER

Company Name

Company Address

Reference Phone Number

Dates Employed from ___ to ____

Supervisor's Name

Job Title

Reason for leaving

Job Duties

Salary

Hourly, Weekly, or Monthly

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SECURITY

*******Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check. As a condition of employment all employees must be “Bondable” & “Insurable”. 

Are You 19 Years Old ?

List states and counties of residence for the past seven years:

Have you had any moving traffic violations?

If Yes, Please Describe:

Have you been charged/convicted of a felony and/or misdemeanor/or served time?

If Yes, Please Describe:

Incident

Incident

City/State

City/State

Charge

Charge

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?
REFERENCES (Do not include relatives)

Please complete 3 references. Your application will not be considered unless 3 references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional references. There must be at least 2 employers within the 3 references

Best Time To Call

Best Time To Call

Best Time To Call

Best Time To Call

Best Time To Call

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs at any time of employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful pass of criminal background, registry, and OIG checks. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Innovation Healthcare Solutions Enterprise Inc. and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

Your Signature

163 Stratford Court, Suite 215

 Winston Salem, NC 27103

For Life-Threatening Emergencies Call 911
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