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ABACARE SERVICES LLC

APPLICATION FOR EMPLOYMENT

PERSONAL DATA - If you have lived at current address less than one year, list previous address

Last name

First name

Middle name

SSN :

Telephone#

Street Address

State

Zip

City

County

Previous Address

State

Zip

City

County

EDUCATION

Date

School, Location

Degree/Diploma

Course Of Study

Date

School, Location

Degree/Diploma

Course Of Study

Date

School, Location

Degree/Diploma

Course Of Study

SPECIAL LICENSES, CERTIFICATIONS OR REGISTRATION

License/Certification Type

License/Certification No

State

Expiration Date

License/Certification Type

License/Certification No

State

Expiration Date

CPR Expiration Date

Last Physical Exam date

Lab TB/Chest

X Ray Date

GENERAL INFORMATION

Are you legally authorized to work in the USA
YesNo

(If you became an employee of Abacare Services LLC, you will be required to provide documentation proving your eligibility to work in the USA)

Have you ever been convicted of a felony or misdemeanor crime?
YesNo

(This does not apply if the conviction has been expunged, is contained in a sealed record, or was ajuvenile conviction.)

A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its occurrence and any rehabilitation you have undergone.

If yes, state the basis for each conviction and the date of the conviction:

Are you able to perform the tasks according to the job description without accommodation?
YesNo

If an accommodation is needed, how would perform the task and with what accommodation?

In case of emergency, notify:

Name

Telephone#

Relationship

Address

WORK EXPERIENCE

Please complete all appropriate items, even if you have already provided us with a resume

Company Name

From

Company Address

Salary (Optional)

Hourly $

Annually $

Describe your most recent job duties and accomplishments:

Name of Current Supervisor

Telephone #

Explain reason for leaving

Company Name

From

Company Address

Salary (Optional)

Hourly $

Annually $

Describe your most recent job duties and accomplishments:

Name of Current Supervisor

Telephone #

Explain reason for leaving

Please list any other work related information you think would be helpful to us in considering youfor employment, such as foreign language competency, additional work experience, volunteerwork, activities, accomplishments, publications, patents, thesis, etc.

REFERENCES

Please list three individuals with whom you have worked who were in a position to evaluate yourperformance

Name

Company Title

Phone #

Name

Company Title

Phone #

Name

Company Title

Phone #

I certify that the facts contained in this application are true and complete. Anymisrepresentation or falsification of information or significant omissions will be cause forrejection of my application or dismissal from employment if discovered at the later date.

Signature

Date

Abacare Services LLC (Abbacare)

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Home Health Care
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