Online Application "*" indicates required fields PERSONAL INFORMATIONFirst Name*Middle Initial*Last Name*Current address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home phoneCell Phone*Email* EMPLOYMENT DESIREDPosition desired*Date available to start* MM slash DD slash YYYY Hours available to work*Are you currently employed?*YesNoIf so, may we contact your current employer?*YesNoHave you ever applied to or worked for us before?*YesNoIf so, when? MM slash DD slash YYYY Reason for leaving?EDUCATIONType of schoolHigh SchoolCollegeTrade, Business, Nursing or OtherName and location of schoolYears attendedGraduate?YesNoSubjects studiedEducation 2 Add additional educationType of schoolHigh SchoolCollegeTrade, Business, Nursing or OtherName and location of schoolYears attendedGraduate?YesNoSubjects studiedEducation 3 Add additional educationType of schoolHigh SchoolCollegeTrade, Business, Nursing or OtherName and location of schoolYears attendedGraduate?YesNoSubjects studiedLicenses, certifications or registrationsThat are pertinent to this application.GENERAL INFORMATIONAre you 18 years of age or older?*YesNoAre you legally eligible to work in the USA?*YesNoDo you have any allergies to animals?*YesNoWhat allergies to pets?WORK EXPERIENCEEmployer Name & AddressStart date (month - year)End date (month - year)Job titleReason for leavingEmployment 2 Add additional employmentEmployer Name & AddressStart date (month - year)End date (month - year)Job titleReason for leavingEmployment 3 Add additional employmentEmployer Name & AddressStart date (month - year)End date (month - year)Job titleReason for leavingREFERENCESName & AddressPhone NumberYears KnownReference 2 Add additional referenceName & AddressPhone NumberYears KnownReference 3 Add additional referenceName & AddressPhone NumberYears KnownEMERGENCY CONTACTName & Relationship*Address*Phone Number*PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I certify that the information on this application and its supporting documents is true and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Superior Home Care to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. I agree to submit to criminal background investigation. If requested, I agree to be screened for illegal substances upon conditional offer of employment or random testing during my employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Superior Home Care serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than reason prohibited by law. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.Applicant Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
