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Gender

Male Female Other

Are You Eligible To Work In The USA?

Yes No

Are You Legal US Citizen?

Yes No

Do You have a Valid Driver's License?

Yes No

Do You have a Car?

Yes No

If Yes, Do You Have Valid Insurance ?

Yes No

Hours You're Available

1-4 Hours 5-8 Hours 9-12 Hours

Schedule Desire

Time Available

Morning Evening Overnight

Are you Available For 24 Hours?

If Yes

3 Days 4 Days 5 Days Other

Check All Languages You Speak

English Mandrin Japanese Somali

French Hindi German Chinese

Spanish Portuguese Turkish Bengali

Arabic Russian Swahili Other

Place a Check By The Condition or Duties You Have Experienced In:

Have You Ever Been Convicted Any Feloney or Misdesmeanor?

Supervisor Or Contact

Describe your Work Responsibility:

May We Contact Your Current Employer

Yes No

Explain About your Current Job

Allevia HomeCare does not discriminate in their hiring practices or in any other decision on the basis of race, color, sex, sexual orientation, citizenship, national origin, veteran status, age and/or physical or mental disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and/or discharge at any time during employment. I understand that Allevia Home Care LLC is under no obligation to consider or reconsider this application at any time, and that acceptance of this application does not constitute an offer of employment.

I authorize “Allevia” to verify any and all information contained within this application, educators, employers, references, consumer credit, private or government agencies and any other individuals who may have knowledge of me or my work experience. I authorize all persons, schools, companies & law enforcement authorities to release any information concerning my background & hereby release any said persons, schools, companies & law enforcement authorities from any liability for any damage whatsoever for issuing this information. I agree to cooperate with such an investigation and release all parties from any and all liability, claims or damages, directly or indirectly, resulting from furnishing such information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.

Restrictive Covenant: I agree not to do business directly with any individual or business entity that Allevia Home Care LLC. has introduced to me or by entering into employment with such individuals or businesses.

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