Have you ever worked for HeartPrint Home Care before? If Yes, when?

How were you referred to HeartPrint Home Care?

Do you have dependable transportation?

Discuss any training or experience working with the elderly, including types of facilities you have worked at.

List experience with performing these duties: light housekeeping, meal preparation, transportation, providing personal cares (bathing dressing, toileting).

List any of the previously mentioned tasks you could not perform.

Times you are available to work.

Times you are NOT available to work.

Can you be called at the last minute in case of emergency?

Can you work every other weekend?

Can you work rotating holidays?

Can you pass a pre-employment drug test?

ACKNOWLEDGEMENT (Please read carefully and sign): In signing this application I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment if revealed after employment commences. I give Heartland Home Care Inc. (trade name HeartPrint Home Care) permission to use any information in this application to enable the company and agents acting on the company's behalf to verify the information contained in this application. I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by HeartPrint Home Care with regard to any of the subject covered by this application. I also understand that in connection with my application for employment or my employment, HeartPrint Home Care will conduct a criminal background investigation and that my employment will be contingent on the result of such investigation. I release HeartPrint Home Care, its agents and affiliated entities as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information. In consideration of my employment and of my being considered for employment by HeartPrint Home Care, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either HeartPrint Home Care or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of HeartPrint Home Care, at any time, can constitute a contract of employment. No representative or agent of HeartPrint Home Care has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results. I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.