♥  Owned and Managed by The Arpiarian Sisters since 1988   ♥  

Employment Application

 

 
BACKGROUND INFORMATION

Telephone -


How did you hear of our agency?
Name of Referral Source:
Are you legally authorized to work in the United States?* Yes No
Note: If you are hired, you will be required to submit proof of legal right to work in the United States.
Are you 18 years of age?* Yes   No
Person to contact in emergency:
Emergency contact telephone number:
 
Position Availability
Position applied for:
Home Health Aide Homemaker
Personal Care Aide Homemaker
Companion Homemaker
What is the date you are available to start work?*
 
Availability must be no less than 10 hours per week.
 
Do you have any problems accepting one (1) hour assignments? Yes No
If yes, Why?
Daily Availability: You must be available to accept assignments at least 3 days/week. We will try to assign you work during your preferred request but cannot guarantee it.
Sunday:from to
Monday:from to
Tuesday:from to
Wednesday:from to
Thursday:from to
Friday:from to
Saturday:from to
 

Please Select One Primary Territory that you are available to work in.*

Territory 1
Chelsea
East Boston
Revere
Winthrop
Territory 2
Cambridge
Everett
Malden
Medford
Melrose
Stoneham
Somerville
Wakefield
Territory 3
Arlington
Bedford
Belmont
Burlington
Concord
Lexington
Waltham
Watertown
Winchester
Woburn
Are you able to work in all the towns in the territory that you have chosen? Yes No
If not, which towns(s) can you not accept assignments in?
 
Have you ever worked for this Company before?* Yes No
If yes, please specify date, facility/division and location:
 
Have you ever applied for employment with this Company before?* Yes No
If yes, please specify date, facility/division and location:
 
Drivers License:* Yes No
If yes, Drivers License #: Expiration Date:
 
EMPLOYMENT HISTORY*
Do you have at least 12 months of work experience? Yes No
If yes, please complete the following:
 
List all employment and include volunteer activities that can be verified. List your employers, starting with present or most recent.
Company & Phone Immediate
Supervisor
Dates of
Employment
Salary
History
Position
Held
Reason for
Leaving
 
Are you employed now?* Yes No
If yes, may we contact your current employer? Yes No
 
Do you have any commitments to another employer which might affect your employment with us?
 
Are you subject to any restrictive covenants from prior employment such as agreements to protect confidential or proprietary information agreements not to compete? If so, please explain:
 
REFERENCES*
Provide the following information regarding 2 persons not related to you who have known you longer than a year.
Name Address & Telephone Number Business Years Acquainted
 
EDUCATION *
Type of School School Name
& Address
Major or Course
of Study
Grad.? Degree or
Certificate
High School
College
College
Graduate School
Trade/Business School
Other
 
Are you certified as Home Health Aide
Where did you receive your certification?
 
Are you currently Licensed, registered or Certified in Massachusetts?* Yes No
If Yes, What Types:
State originally issued:
Give, License, registration or certification number: Expiration Date:
Serial Number:
 
Were you in the U.S. Armed Forces? Yes No
If yes, what Branch?
Dates of Duty? From: To:
Rank at Separation: Briefly describe your duties:

Note: This company does not discriminate on the basis of National Guard or Reserve Unit Duty obligations.
 
Please list any other information you think would be helpful to us in considering you for employment, such as organizations, activities, accomplishments, computer skills, etc. Exclude all information indicative of age, sex, orientation, race religion, color, national origin, disability or handicap.
 
AGREEMENT
 
I certify that all information on this application and any other material provided by me is true and complete. I agree that falsified information, misrepresentations or omissions on this application, or accompanying resume or other materials will disqualify me from consideration for employment and will be considered justification for dismissal whenever discovered.
 
Unless otherwise noted, I authorize Metropolitan Home Health Services, Inc. or its agent to investigate and/or verify all information in this application, including contacting all persons, schools, current employer (if applicable), previous employers and other individuals or entities named on this herein (and those named on accompanying resume, if any). I hereby authorize my former employees and other third parties named on this application release to information pertaining to my work record, habits and performance. In doing so, I hereby release them and Metropolitan Home Health Services, Inc. and its agents from all liability which may flow from the release of such information.
 
I understand that if I am hired my employment will be on an at-will basis, for no determine term. As such, I understand that I will enjoy the right to terminate my employment at any time, and that Metropolitan Home Health Services, Inc. will similarly enjoy the right to terminate my employment, at any time, with or without cause. This status can only be modified by a written document setting forth such modification, signed by both me and an authorized representative of Metropolitan Home Health Services, Inc. I further acknowledge that I am expected to abide by all Company rules, regulations, and policies, written or unwritten, but that such rules, regulations and policies do not create a contract between me and the Company or otherwise restrict the right of either party to terminate the employment relationship.
 
Applicant's Signature:*   Date:
 
By putting your name in the Applicant's Signature box you are digitally signing and you agree that all information on this application is true, complete and correct.
 
 
All labels with a * are required.
 
Massachusetts General Laws c. 149s19B requires that the following statement be included on employment applications: "It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability."
 
 

 

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