Position(s) applied for
Date of Application
Last name
First Name
Zip Code
Telephone #
Social Security #
DL # & state
Name and telephone # to contact in case of emergency
Email Address:
How did you hear about this position?
Have you ever filed an application with Angels Around the Clock Homecare before? yes
Are you currently employed? yes
If yes, may we contact your employer? yes
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (proof of citizenship or immigration status will be required upon employment) yes
On what date would you be available for work?
Are you available to work:
Can you travel if the job requires it? yes
Do you authorize AATC to conduct a criminal background check of records of conviction, arrests, indictments? If so list addresses for the last 7 years. yes
Addresses? List addresses for the last 7 years. Use an additional sheet if necessary.
Within the past seven years have you been convicted of a felony crime? yes
If yes, please explain
Do you give authorization for the company to check your credit history via a credit reporting bureau as a condition of employment? yes
If yes, birthdate is needed for reporting purposes: _____/_____/_______
Do you currently have any relatives working for Angels Around the Clock? If so, please list
EMPLOYMENT HISTORY (last four employment experiences).
Indicate any foreign language you speak, read and/or write. (do not include English)
Describe any specialized training, apprenticeships, skills, talents and any extra-curricular activities.
List all licenses and/or certifications pertinent to the position(s) for which you are applying.
Describe any specialized skills., equipment, or software programs in which you are proficient and level of expertise.
Summarize any special job-related skills and qualifications gained from any previous employment or experience.
Provide comment in your own words why you wish to work here.
PROFESSIONAL REFERENCES (recent supervisors preferred).

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