If you are considered for a position, we may contact your references and would ask that you notify them in advance. Please do not list relatives or family/relations.

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

• Please read "Applicant Note" below.
• Complete all parts of this application.
• Application will be valid for 60 days.

Applicant Note: This application form is intended for use in evaluating your qualifications for employment with us, an independently owned and operated Home Instead franchise. 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 is required prior to employment.

Other Names Previously Used:

	Last Name	First Name	Middle Name
1.
2.

Emergency Contacts
Please provide two emergency contacts.

Full Name	Phone Number	Email	Relationship
*	*	*	*

* Have you ever submitted an application here before?

Yes   No

If yes, when?

* Have you ever been employed here before?

Yes   No

If yes, when?

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

Yes   No

* Date of Birth:

Due to the nature of this industry, no guarantee can be made as to the schedule or the amount of hours worked. Also please note, we rely upon the availability you state below when making our hiring decision. If your availability changes from what is stated below during the hiring process or at any time during your employment, you must contact our office immediately with the change. Depending upon the change, Home Instead reserves the right to not further consider you for employment. Completion of a more detailed availability form (to which you will be held in compliance with) will be required later in the application process - for now choose the options that best describe your availability generally.

* What date are you available to begin work?:

* Total hours preferred to work per week:

* Please indicate all areas of availability (check all that apply):

Hourly    Mornings    Afternoon    Evenings    Overnights    Live-In    Weekends

I certify that I have read and understand the applicant note on page one 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 prior to and during employment.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT FOR EMPLOYMENT

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date: