Help At Home, Inc. Online Employee Application

Employer's Name:

Street Address:

Job Title:

Immediate Supervisor and Title:

Reason for leaving:

Help at Home, Inc./Oxford Healthcare Online Employee Application

Check the position(s) you are applying for :
Homemaker/Home Care Aide	Certified Nursing Assistants/Nursing Assistants
Housekeeper/Staffing Services	Licensed Practical Nurse
Attendant Care	Registered Nurse
Companion	Other
if other, please fill in the position you are applying for:

Referral Source?:	Internet	Newspaper	Employee	Walk-in
Name of Source (if applicable):

Please enter the location of the Help at Home/Oxford Office nearest to you? For a list of all Help at Home/Oxford locations click here.

Check this box if you are unsure what Help at Home/Oxford Office is nearest to you. If you have any questions about our locations feel free to contact our Chicago Corporate Office between the hours of 8am - 5pm Monday through Friday toll free 1(800) 404-3191.

	First Name	Last Name	Middle Initial

Address 1	City

Address 2	State	Zip Code

	Primary Telephone Number	Secondary Telephone Number (cell)
	( ) -	( ) -

Email Address

Social Security Number

- -

Are you eighteen years or older?

YES

Required fields are in RED

Have you ever been employed with Help at Home, Inc or Oxford Healthcare?		YES	NO
	if yes, give date:
Are you a preferred caregiver?		YES	NO
If you are under eighteen, can you furnish a work permit?		YES	NO
Have you filed an application here before?		YES	NO
	if yes, give date:
Are you legally eligible to be employed in this country? ............ ............... ................ (Proof of U.S. Citizenship or immigration status will be requested upon employment.)		YES	NO
Are you able to meet attendance requirements of the position? *		YES	NO
Will you work overtime if requested?		YES	NO
Have you ever been bonded?		YES	NO
Have you ever been convicted of a crime or felony?		YES	NO

If yes, please provide date(s) and please explain in the space provided:
* Most assignments are during normal business hours (Mon. - Fri. 8am - 5pm) ; however, some assignments require workers to be available during evening and/or weekend hours.

List your last four (4) employers, assignments or volunteer activities; starting with the most recent and including military experience. Explain any gaps in employment in the Comments section below.

Dates Employed:	FROM:	TO:
Below Summarize the nature of the work performed and job responsibilities:

Hourly Rate:	START:	FINISH:
Salary:	START:	FINISH:

May we contact for reference?

YES

LATER

Dates Employed:	FROM:	TO:
Below Summarize the nature of the work performed and job responsibilities:

Hourly Rate:	START:	FINISH:
Salary:	START:	FINISH:

May we contact for reference?

YES

LATER

Dates Employed:	FROM:	TO:
Below Summarize the nature of the work performed and job responsibilities:

Hourly Rate:	START:	FINISH:
Salary:	START:	FINISH:

May we contact for reference?

YES

LATER

Dates Employed:	FROM:	TO:
Below Summarize the nature of the work performed and job responsibilities:

Hourly Rate:	START:	FINISH:
Salary:	START:	FINISH:

May we contact for reference?

YES

LATER

COMMENTS: (including explanation of any gaps in employment)

SKILLS AND QUALIFICATIONS :

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for work at our company.

EDUCATIONAL BACKGROUND
NAME AND LOCATION	YEARS COMPLETED	DID YOU GRADUATE?	COURSE OF STUDY
High School:
		YES NO
College:			Major:
		YES NO
			Degree:

Other:
		YES NO

NAME		TELEPHONE	YEARS KNOWN
**REFERENCES (Do not list relatives/family members )***
1.
2.
3.

If you do not complete this application in its entirety we will not be able to process it. So recheck your work before clicking the "Submit Application" button.

Please read the following information below.

By agreeing to these terms, the applicant affirms that all information they have provided is true, accurate and correct. Any applicant providing Help At Home, Inc./Oxford Healthcare with any false information will not be considered for employment with the Company. Any employee discovered to have provided false information on their employment application may be subject to immediate termination.
Check this box and type in your FULL name (FIRST AND LAST) if you fully understand and agree to the terms above.
TYPE IN YOUR FULL NAME:

IMPORTANT: You must agree to the terms above and type in your full name in order for us to process your application.

*Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, handicap, veteran status, marital status, sexual orientation, or any other characteristic protected by law.

*Help at Home, Inc/Oxford Healthcare is an equal opportunity employer.

Copyight 2009 Help at Home, Inc.