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Date(Required)

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone Number(Required)

Emergeny Contact Name and Number(Required)

Email(Required)

How did you hear about us

Type of employment desired(Required)

Please Specify Days and Hours Available(Required)

Position applied for(Required)

Full-time

Part-time

PRN

Current hourly Pay Rate $(Required)

Desired pay Per Hour $(Required)

Are you legally eligible to work in the US?(Required)

Yes

Are you available to work Call Outs, if needed?

Yes

Have you ever been employed with Live Well Home Care?(Required)

Yes

If yes, when?

Why did you leave?

Do you have any friends or family employed with Live Well Home Care?

Yes

Have you been convicted of a crime in the last seven (7) years?(Required)

Yes

If yes, please explain

During the hiring process, do you agree to provide a criminal background check?(Required)

Yes

Documents	Current	Expires
CNA Certification	Yes No
CPR/ First Aid	Yes No
Driver's License	Yes No
TB Screening	Yes No

Institution	Field of study	Graduated
		Yes No
		Yes No
		Yes No

Employer 1

Employer Name:(Required)

First

From:(Required)

To:(Required)

Phone(Required)

Responsibilities:(Required)

Address

Street Address

Job Title:(Required)

Starting Hourly Rate $:(Required)

Supervisor Name:(Required)

Phone(Required)

Reason for leaving:

Final Hourly Rate $:

May we call to verify?(Required)

Yes

Employer 2

Employer Name:

First

From

Phone

Responsibilities:

Address

Street Address

Job Title:

Starting Hourly Rate $:

Supervisor Name:

First

Phone

Reason for leaving:

Final Hourly Rate $:

May we call to verify?

Yes

Employer 3

Employer Name:

First

From

Phone

Responsibilities:

Address

Street Address

Job Title:

Starting Hourly Rate $:

Supervisor Name:

First

Phone

Reason for leaving:

Final Hourly Rate $:

May we call to verify?

Yes

References: List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please)

Name	Relationship	Years acquainted	Phone Number

PLEASE READ CAREFULLY

In exchange for the consideration of my job application by Live Well Home Care, LLC, I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position. Both the undersigned and Live Well Home Care, LLC may end the employment relationship at any time. ______(Initial) I further understand that my employment with the company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary or thereafter, my employment relationship with Live Well Home Care, LLC is terminable at will for any reason by either party ______(Initial) I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Live Well Home Care, LLC permission to contact schools, all previous employers (unless otherwise indicated), references, and perform a criminal background check conducted as required by state law. I hereby release Live Well Home Care, LLC from any liability because of such contact. ______(Initial) CERTIFICATION AND RELEASE I certify that I have read and understand the application 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 misrepresentation of facts called for 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 consumers reporting bureaus, to verify any 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 understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment Live Well Home Care is an equal opportunity employer. We strive to promote equality and diversity within the Agency, and this policy applies to all our employees, job candidates, volunteers, and contractors as well. Being an equal opportunity employer means we do not discriminate in employment on basis of nationality, color, sex, age, disability, religion, sexual orientation, and any other means as protected by all applicable state and federal laws If I drive a vehicle for Live Well Home Care, LLC, I will herein provide the following information: Valid Driver's License A copy of car insurance information

Digital Signature(Required)

Date(Required)

Live Well Home Care, LLC is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with Live Well Home Care, LLC depends solely on your qualifications.

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