Apply — Autumn Home Plus

Personal Information

Name

First Name

Last Name

Street Address

City

State

ZIP Code

Home Phone

Cell Phone

Emergency Contact Number

E-Mail

Legal Information

Have you ever been convicted of a felony?

Have you ever been convicted of a misdemeanor?

Transportation Information

Do you have reliable transportation to and from work?

Employment Information

Position Applying For

CNA

CMA

Nurse Administration

Employment Desired

Desired hourly pay?

How many hours can you work a week?

Can you work nights?

Can you work weekends?

Days/hours available to work

Select days available

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Cooking Skill

How much can you lift?

Experience Information

Please list any training or experience working with the elderly

What would you like most about working with the elderly?

Education Information

High School

Location

College

Location

Trade School/Other

Location

Degrees/Certifications

Language other than english that you speak?

Employment History

Company

Employment Date

Contact

Phone

Responsibilities

Company

Employment Date

Contact

Phone

Responsibilities

Company

Employment Date

Contact

Phone

Responsibilities

May we contact your current or past employer?

Autumn Home Plus, Inc. is an equal employment opportunity employer. All applicants will be considered without regard to age, color, national origin, religion, disability, sex, or other protected status in accordance with applicable federal and state equal employment opportunity laws.

References

Reference Name

First Name

Last Name

Reference phone number

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Reference Name

First Name

Last Name

Reference phone number

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Driver license number

State

Have you ever been employed here?

I certify that all answers and statements I have made on this application (and resume or other supplementary materials) are true and complete without omissions. I understand that any false information will result in a refusal to hire or immediate discharge if I am employed. I authorize any of the persons or organization named in this application to give you complete information and records regarding my employment, education, character and qualifications.

If hired I will be responsible for familiarizing myself with all the rules and regulations of Autumn Home Plus, Inc. as they presently exist or are later modified. If hired, I understand my employment can be terminated, at the discretion of the company or at my option, without notice, at any time, except as specifically set forth in writing in a current individual employment agreement, which I have entered into with the company.

I also understand that no representative of Autumn Home Plus, Inc. has any authority to enter into any employment agreement for any specified period of time, or to ensure me of any future position, benefits, or terms and conditions of employment, except as specifically stated in a current written agreement signed by the owner.

I understand this application is not an offer of employment.

By hitting the submit button below, I authorize Autumn Home Plus, Inc. to investigate all statements contained in this employment application as they may deem necessary in arriving at an employment decision.

Submit Resume (Max File Size:10mb)

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Thank you! Please Submit Resumes to info@autumnhomeplus.com