Application for Employment An Equal Opportunity Employer. If applicable to Cornerstone Home Care Services, reasonable accommodation under the Americans with Disabilities Act will be provided as required by law. By completing this application, you acknowledge that Florida is an At Will employment state and that any offer of employment is conditioned upon completing an INS Form I-9, a clear background check, and providing appropriate documents for identification and fulfilling any other hiring requirements. You also acknowledge that failure to do so is subject to immediate termination. Step 1 of 7 14% Pre-Employment RequirementsName First Middle Last Address Street Address City State / Province / Region ZIP / Postal Code Social Security NumberPhone NumberIf hired can you provide evidence of legal eligibility to work in the United States?YesNoEmail Position DesiredWage/Salary DesiredDate of Birth Date Format: MM slash DD slash YYYY Have you EVER been convicted of a felony, or a misdemeanor involving any violent act, use or possession of a weapon, or theft, forgery, act of dishonesty for which the record has not been sealed or expunged, or do you have such a case pending?YesNoIf YES when?If YES where?Date you can begin work? Date Format: MM slash DD slash YYYY Are you 18 years or older?YesNoIf under 18 years of age, you will be required to submit a birth certificate and signed parental consent form as required by the Department of Labor. Name of high school attendedCity and State City State / Province / Region Did you Graduate?YesNoIf NO, do you have a GED?YesNoName of College or technical schoolCity and State City State / Province / Region Did you Graduate?YesNoDegreeMajorCertificate/DiplomaAre you presently enrolled in School?YesNoIf Yes, give the name, address, telephone number and expected degree date?List any job-related skills or accomplishments, including military service Your Availability For WorkMondayFrom : HH MM AM PM MondayTo : HH MM AM PM TuesdayFrom : HH MM AM PM TuesdayTo : HH MM AM PM WednesdayFrom : HH MM AM PM WednesdayTo : HH MM AM PM ThursdayFrom : HH MM AM PM ThursdayTo : HH MM AM PM FridayFrom : HH MM AM PM FridayTo : HH MM AM PM SaturdayFrom : HH MM AM PM SaturdayTo : HH MM AM PM SundayFrom : HH MM AM PM SundayTo : HH MM AM PM Total number of hours per week you are available to workPlease list any special requests or needs for a work schedule? Give three references who are NOT former employers who we may contact1.Name First Last OccupationHow do you know them, and for how long?Phone Number2.Name First Last OccupationHow do you know them, and for how long?Phone Number3.Name First Last OccupationHow do you know them, and for how long?Phone Number Employment History List the names of employers with present or last employer listed first. Please note that we may not contact your present employer until after you have been offered an assignment. Application must account for periods of more than one month break in employment.First EmployerName of Employer First Middle Last Job TitleDutiesAddress Street Address City State / Province / Region ZIP / Postal Code Dates of EmploymentFrom Date Format: MM slash DD slash YYYY Dates of EmploymentTo Date Format: MM slash DD slash YYYY Supervisor's Name First Middle Last Hourly pay or salaryStarting Pay:Hourly pay or salaryEnding Pay:Telephone NumberReason for leavingSecond EmployerName of Employer First Middle Last Job TitleDutiesAddress Street Address City State / Province / Region ZIP / Postal Code Dates of EmploymentFrom Date Format: MM slash DD slash YYYY Dates of EmploymentTo Date Format: MM slash DD slash YYYY Supervisor's Name First Middle Last Hourly pay or salaryStarting Pay:Hourly pay or salaryEnding Pay:Telephone NumberReason for leavingThird EmployerName of Employer First Middle Last Job TitleDutiesAddress Street Address City State / Province / Region ZIP / Postal Code Dates of EmploymentFrom Date Format: MM slash DD slash YYYY Dates of EmploymentTo Date Format: MM slash DD slash YYYY Supervisor's Name First Middle Last Hourly pay or salaryStarting Pay:Hourly pay or salaryEnding Pay:Telephone NumberReason for leaving ResumePhysical Examination (within the past 6 months)Negative PPD or Chest X-Ray result (within the past 12 months)CPR or ALS/BLS cardDriver’s LicenseSocial Security CardProfessional License (RN, LPN, CNA)Liability insurance (if applicable)Automobile Insurance (if applicable)Automobile Registration (if applicable)Voided checkCertifications (e.g. Med. Tech, IV certification)CEU’s (HIV/AIDS, Domestic Violence, Alzheimer’s) Carefully read each statement before signing at the bottom: I certify that all of the information provided in this employment application is true and complete to the best of my knowledge, and I authorize investigation of all statements contained in this application, including a criminal background check and credit history check. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date. I understand and acknowledge that unless otherwise defined by applicable law or written agreement with CORNERSTONE HOME CARE SERVICES, any employment/independent contractor relationship will be considered “employment at will.” This means the employee/independent contractor may resign at any time and CORNERSTONE HOME CARE SERVICES may discharge the employee/independent contractor at any time, with or without cause, and with or without advance notice. I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employer, and other organization to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I have read, understand, and agree to the above statements:SignatureDate Date Format: MM slash DD slash YYYY