Can you work at nights? YesNO	Employment desired Full TimePart TimeFull or Part Time	Day / hours No prefMonTueWedThuFriSatSun

Are you a citizen? YESNO	If no, are you authorized to work in the U.S.? YESNO

Have you ever worked for this company? YESNO

Do you have a Driver's License? YESNO

License Type OperatorCommercialChauffer	Expiration Date

Have you had any accidents during the past three years? YESNO	If yes, how many?

Have you had any moving violations during the past three years? YESNO	If yes, how many?

Have you ever been convicted of a crime? YESNO

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Education

High school	Address

From	To

Did you graduate YESNO	Diploma

College	Address

From	To

Did you graduate YESNO	Degree

Other	Address

From	To	Did you graduate YESNO

References

Reference 1

Full name	Relationship
Company	Phone

Address

Reference 2

Full name	Relationship
Company	Phone

Address

Previous Employment2

First Employment

Company	Phone
Address	Supervisor

Job Title	Starting Salary:$	Ending Salary:$	Responsibilities:

From	To	May we contact your previous supervisor for a reference? YESNO

Second Employment

Company	Phone
Address	Supervisor

Job Title	Starting Salary:$	Ending Salary:$	Responsibilities:

From	To	Reason for Leaving	May we contact your previous supervisor for a reference? YESNO

Third Employment

Company	Phone
Address	Supervisor

Job Title	Starting Salary:$	Ending Salary:$	Responsibilities:

From	To	Reason for Leaving	May we contact your previous supervisor for a reference? YESNO

Military Service

Have you ever been in the Armed Forces? YESNO	Branch:$	From:$	To:

Rank at Discharge:	Type of Discharge:	If other than honorable, explain:

Attachments

CPR/FA/AED And Certifications	Drivers License
Social Security Number	Negative TB Test
Certifications and Licensures	Resume
Three References	Vehicle Insurance and Registration

PLEAS READ CAREFULLY

ERS Home Care AFFIRMATION OF FACT/INVESTIGATION WAIVER

In exchange for the consideration of my job application by ERS Home Care, I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other organization practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of ERS Home Care, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President or designated Executive Staff of the organization. Both the undersigned and ERS Home Care may end the employment relationship at any time, without specified notice or reason. If employed, I understand that ERS Home Care may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give ERS Home Care permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release ERS Home Care from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, ERS Home Care may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, ERS Home Care will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act. I further understand that my employment with ERS Home Care shall be probationary for a period of 180 days, and further that at any time during the probationary period or thereafter, my employment relation with ERS Home Care is terminable at will for any reason by either party.

Signature	Date

Exceptional Residential Services Home care is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this organization depends solely on your qualifications.