LWF Home Care Specialists

1-800-631-6550
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Employment Application Form

Worksite Preference Worksite

Applicant Information Name
Address
Phone Number Alternate Number
Email Address Emergency Contact
Are you 18 years or older? Yes No
If hired, can you present evidence of your legal right to work in the United States? Yes No

(The immigration Reform & Control Act of 1986 requires you to furnish proof of your employment authorization and identity before you can begin work.)

Have you ever been convicted of a felony or serious misdemeanor? Yes No

(Convictions for marijuana-related offenses that are more than two years old need not be listed.)

If yes, state nature of the crime(s), when and where convicted, and disposition of the case

Employment Desired Position Start Date Salary Desired
Are you employed? Yes No If Yes, may we inquire of your Present Employer? Yes No
Ever Applied to this Company Before? Yes No
If Yes, where and when?
Referred By

Education

High School
School Name	Location	Years Completed	Diploma/Degree	Majors/Subjects

Business School
School Name	Location	Years Completed	Diploma/Degree	Majors/Subjects

University
School Name	Location	Years Completed	Diploma/Degree	Majors/Subjects

Graduate
School Name	Location	Years Completed	Diploma/Degree	Majors/Subjects

List any Vocational Schools Attended

List any professional or vocational certifications, licenses, or registrations that you currently hold or have held in the past

Describe any specialized training, apprenticeship skills, extracurricular activities, honors, scholarships, appointments, awards, or special recognition that you have received

References

Name	Company	Title	Telephone	Email

Relationship

Name	Company	Title	Telephone	Email

Relationship

Name	Company	Title	Telephone	Email

Relationship

Employment History

Company Name	Phone	Position Held	Pay Rate

Company Address

Type of Business	Reason for Leaving	Supervisor Name	From/To

Duties and Achievements

Company Name	Phone	Position Held	Pay Rate

Company Address

Type of Business	Reason for Leaving	Supervisor Name	From/To

Duties and Achievements

Company Name	Phone	Position Held	Pay Rate

Company Address

Type of Business	Reason for Leaving	Supervisor Name	From/To

Duties and Achievements

Applicant Affirmation

I here by affirm, that the information in this application is true and accurate. If any of the following turns out to be false or misleadinq, LWF Home Care Specialists may dismiss me immediately at its sole discretion. If hired, I agree to provide documentation authorizing me to work in the United States. I authorize LWF Home Care Specialists to contact my previous employer for relevant Information about me; and I authorize LWF Home Care Specialists to release the information herein, as reasonably required, to any client of LWF Home Care Specialists, or insurance company; and I authorize LWF Home Care Specialists to give future prospective employers relevant information about my employment, if so requested. I understand my employment may be conditioned upon my passing a physical examination, and/or a drug and alcohol test, and if hired, I agree to be subject to alcohol and drug testing for my safety and the safety of others; and in connection with any job-related injuries, as LWF Home Care Specialists deems necessary.

I agree? Yes No