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JOB APPLICATIONRESOLUTE HOME CARE SERVICES LLCOFFICE PHONE NUMBER AVAILABLE FAX PHONE NUMBER AVAILABLERESOLUTE HOME CARE SERVICES is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.Please fill out all sections below:Applicant InformationApplicant Name:Employment PositionPosition(s) applying for: CNA CAREGIVER COMPANIONHow did you hear about this position?What days are you available for work?What hours or shift are you available for work?If needed, are you available to work overtime?On what date can you start working if you are hired?Do you have reliable transportation to and from work?Salary desired:Personal InformationHave you ever applied to or worked for RESOLUTE HOME CARE SERVICESbefore?YesNoIf yes, when?Do you have any friends, relatives, or acquaintances working for RESOLUTE HOME CARE SERVICESIf yes, state name & relationship:Yes NoAre you 18 years of age or older?YesNoAre you a U.S. citizen or approved to work in the United States?YesNoWhat document can you provide as proof of citizenship or legal status?Will you consent to a mandatory controlled substance test?YesNoDo you have any condition which would require job accommodations?YesNoIf yes, please describe accommodations required below.Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes NoIf yes, please state the nature of the crime(s), when and where convicted and disposition of the case:(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)Job Skills/QualificationsPlease list below the skills and qualifications you possess for the position for which you are applying:(Note: RESOLUTE HOME CARE SERVICES LLC complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )Education and TrainingAre you a member of the Armed Services?What branch of the military did you enlist?What was your military rank when discharged?How many years did you serve in the military?What military skills do you possess that would be an asset for this position?Previous EmploymentEmployer Name:Job Title: Supervisor Name:Employer Address:City, State and Zip Code: Employer Telephone:Dates Employed:Reason for leaving:Employer Name:Job Title:Supervisor Name:Employer Address:City, State and Zip Code: Employer Telephone:Dates Employed:Reason for leaving:Employer Name:Job Title:Supervisor Name:Employer Address:City, State and Zip Code: Employer Telephone:Dates Employed:Reason for leaving:AT-WILL EMPLOYMENTThe relationship between you and the RESOLUTE HOME CARE SERVICES LLC is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the RESOLUTE HOME CARE SERVICES LLC. No representative of RESOLUTE HOME CARE SERVICES LLC has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.Applicant Signature: Dated: