* = Required Information
APPLICANT NOTE: This application is used to evaluate your qualifications for employment with Reprieve Homecare. Please answer all questions accurately and completely. All qualified applicants will be considered regardless of age, race, sex, national origin, disability, and any other status protected under state or local law. screen
PERSONAL INFORMATION
Applicant Name:



Address:




Yes No

Yes No
EDUCATION
Minimum education requirement is High School Diploma or GED
High School/GED
Yes No
College/University
Yes No
Vocational/Technical
Yes No
SKILLS AND QUALIFICATIONS
Dementia/Alzheimer’s Care Training Home Care Experience Bilingual


Yes No
Yes No
AVAILABILITY
There is no guarantee as to the schedule or the number of hours worked
Full-Time Part-Time PRN
Yes No
Please indicate the days and times that you are available to work:
PREFERENCES
Please indicate the locations you are willing to work
Rockdale Newton Henry Walton Gwinnett
Yes No
Dogs Cats
Yes No
WORK HISTORY
Please provide at least Five (5) years of work history if available
Most Recent Employer (1)
Date Employed:


Employer (2)
Date Employed:


Employer (3)
Date Employed:


Employer (4)
Date Employed:


PLEASE READ CAREFULLY BEFORE SIGNING

I certify that the information provided in this employment application is accurate and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in dismissal if discovered at a later date.

I authorize the investigation of any and all statements contained in this application. I also authorize any school, current employer (except as previously noted), past employers, and other organizations named in this application to provide relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that I may be required to successfully pass a drug screening examination. I understand that this application is not an employment contract. Subsequent employment does not guarantee employment for a definite period of time. If employed, I understand that I have been hired at the will of the employer and my employment may be terminated at any time with or without cause or notice.
My signature below certifies that I have read, understand, and agree to the above disclosures.
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