Welcome to a Caring Hand

APPLICATION FOR EMPLOYMENT
A Caring Hand, LLC. offers equal employment opportunity to all applicants for employment and to all employees regardless of sex, age, race, color, religious creed, sexual orientation, national origin, ancestry, marital status or disability.

Date:
Last Name:
First Name:
Middle Initial:
Present Address:
City:
State:
Zip:
Previous Address:
City:
State:
Zip:
Day Telephone:
Eve. Telephone:
Other names under which you have worked:
Are you a U.S. citizen or authorized to work in the U.S. on an unrestricted basis?	yes no
Can you, at time of orientation, submit: Proof of your legal right to work in U.S.?	yes no
A birth certificate or other proof of age?	yes no
Current driver’s license number:
State:
Expiration Date:
Person to be notified in an emergency:
Name:
Address:
Telephone:
Position(s) applied for:
Salary Requirement:
Specify:	Full-Time Part-Time Per Diem Temp
Days and Hours if Part-Time:
Shift preferred:
Were you previously employed by VNHSC or A Caring Hand?	yes no
If yes, when and where?
Names of relatives employed by VNSHC or A Caring Hand?
If an offer is extended, when would you be available for work?
How did you become aware of the position for which you are applying? Please give name of individual or source ( friend, web site, relative, newspaper, agency)
Do you have a reliable method of transportation to use if you are hired to work in this facility?	yes no
Name of School
Address of School
No. of Years Attended
Diploma/Degree
Date Received
*Professional and technical applicants only*
Professional License No.
Type of License
Date and State of Issue
Expiration Date
Section 31-51 (i) of the Connecticut General Statues requires that this portion of the application be detached when the application is to be read by anyone other than a member of the Department of Human Resources. Any person whose criminal records have been erased pursuant to section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath. Criminal records subject to erasure pursuant to section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes are records relating to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolle, a criminal charge for which the person was found not guilty or a conviction for which a person received an absolute pardon. The applicant is NOT required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a of the Connecticut General Statutes.
Have you ever been convicted of a felony?	yes no
If yes, please give information regarding the charge and disposition of the case
Applicant Signature
This section must be completed in full.
Are you presently employed?	yes no
May we contact your present employer?	yes no
Starting with your most recent position, state your last three employment experiences, please complete even if application is accompanied by a resume
From Mo./Yr.
To Mo./Yr.
Name of Employer
Address of Employer
City
State
Zip
Supervisor
Phone
Job Title & Duties
Starting Salary
Ending Salary
Reason for leaving

From Mo./Yr.
To Mo./Yr.
Name of Employer
Address of Employer
City
State
Zip
Supervisor
Phone
Job Title & Duties
Starting Salary
Ending Salary
Reason for leaving

From Mo./Yr.
To Mo./Yr.
Name of Employer
Address of Employer
City
State
Zip
Supervisor
Phone
Job Title & Duties
Starting Salary
Ending Salary
Reason for leaving

References-Please do not list relatives
Name
Occupation
Address
Phone

Name
Occupation
Address
Phone

Name
Occupation
Address
Phone
Do you speak, read, or write in any language other than English?	yes no
Please use this space to list and/or describe any additional skills you possess (i.e. computer hardware/software, typing (wpm), etc.
PLEASE READ CAREFULLY Please DO NOT respond to the following questions until after you have read and/or discussed the job description for the position for which you are applying. Do you believe you would be able to perform the essential functions of the job for which you are applying? yes no Is there any accommodation that you believe can reasonably be made which would permit you to perform the essential functions of the job for which you are applying? yes no If yes, please explain I hereby certify that the answers to the foregoing questions are true to the best of my knowledge and agree to have any of the statements checked by A Caring Hand unless I have indicated to the contrary. I am aware that a more detailed investigation concerning background and credit may also be conducted, if applicable to the job for which I am applying, and I hereby authorize such an investigation. I understand that employment is contingent upon satisfactory completion of reference checks and that, upon my written request, information on the nature and scope of an inquiry, if one is made, will be provided to me. Should a job offer be made, I consent to taking a pre-placement physical examination and such future examinations as may be required by A Caring Hand. I understand that any job offer or my continuing employment, if hired, is contingent upon my being physically, mentally and medically able with or without reasonable accommodation, to successfully perform the essential functions of my job. I understand that as part of my pre-placement physical examination, upon which any offer of employment is contingent, I will be required to successfully pass a drug screening test. The test will be administered at A Caring Hand’s expense, and will require me to provide a urine specimen for analysis. The urine specimen will be analyzed for the presence of marijuana, cocaine, phencyclidine (PCP), opiates and amphetamines. I agree to wear or use all protective clothing or devices required by the facility and to comply with all safety policies and procedures. I understand that nothing contained in this employment application is intended to lead to or create an employment contract between A Caring Hand or any subsidiary of affiliate and myself which would in any way restrict the right of the company to terminate my employment at will. I further understand and agree that the employment relationship that may result from any application will be employment at will, and either I or A Caring Hand or any subsidiary or affiliate may terminate the relationship at any time. I understand that any misrepresentation or falsification can be grounds for refusal of employment. I further understand that, if employed, any false statements or misrepresentations herein or in conjunction with the application process may be cause for dismissal. I understand that all applications and/or resumes submitted for employment consideration become the property of A Caring Hand.
Applicant Signature
Date
BACKGROUND INQUIRY RELEASE I understand that an investigative background inquiry is to be made on myself including, but not limited to, consumer credit history, criminal history, driving history and other reports. These reports may include personal reference information as to my character, work habits, job performance and experience, along with reasons for termination of past employment. I further understand that information will be requested from various Federal, State and other agencies which may maintain records concerning past activities relating to my driving, credit performance, criminal conduct, civil court, and other experiences. I authorize, without reservation, any party or agency contacted to furnish the above information. I hereby consent to your obtaining the above information. And, I further understand that to aid in the proper identification of my file or records, I am providing the following information, as well as any other information that may be required at a later date.
Social Security Number:
Date of Birth:
I will consent to a drug test prior to date of hire: Yes No