Iowa Home Care - Employment Application

Step 1

* First Name
Middle Initial
* Last Name
Email Address
Social Security #
Professional License Number
Professional License Type
Street Address
City
State
Zip Code
Day Phone
Evening Phone
18 years of age?
Have you ever been convicted of a crime in the last 7 years? If Yes, a conviction will not necessarily disqualify you for employment.
Are you legally eligible to work in the U.S.?
How did you hear about Iowa Home Care? Newspaper Online Friend Employee
If Employee, Their name:

Step 3

High School
1. High School Name and Address
2. Years Completed:
3. Did You Graduate?
4. Diploma / Degree
College
1. College Name and Address
2. Years Completed:
3. Did You Graduate?
4. Diploma / Degree
Post College
1. Name and Address
2. Years Completed:
3. Did You Graduate?
4. Diploma / Degree
Trade, Business, or Other Schooling
1. Name and Address
2. Years Completed:
3. Did You Graduate?
4. Diploma / Degree

Step 4 - Special Skills and Qualifications

List skills relevant to the position applied for
Have you had experience with home health care in the past? Explain.
What do you like about health care?
Why do you want to work for Iowa Home Care, LLC?
Describe a specific situation where you have provided excellent customer service. Why was this effective?

Step 5 - Employment Experience

Employer 1
1. Employer Name
2. Position
3. Employment Dates
4. Employer Address
5. Duties & Responsibilities
6. Reason For Leaving
7. Salary Start/End
Employer 2
1. Employer Name
2. Position
3. Employment Dates
4. Employer Address
5. Duties & Responsibilities
6. Reason For Leaving
7. Salary Start/End
Employer 3
1. Employer Name
2. Position
3. Employment Dates
4. Employer Address
5. Duties & Responsibilities
6. Reason For Leaving
7. Salary Start/End
Employer 4
1. Employer Name
2. Position
3. Employment Dates
4. Employer Address
5. Duties & Responsibilities
6. Reason For Leaving
7. Salary Start/End

Step 6 - References

Please give the names of three professional references, whom you have known at least one year.
Reference 1
1. Name
2. Address & Phone Number
3. Business
4. Years Acquainted
Reference 2
1. Name
2. Address & Phone Number
3. Business
4. Years Acquainted
Reference 3
1. Name
2. Address & Phone Number
3. Business
4. Years Acquainted

I agree to the following:

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contains herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

Disclosure: In connection with your application for employment, we may procure a consumer report which may contain public information, such as your driving record, as part of the process of considering your candidacy as an employee with our organization.  A copy of your rights under the federal Fair Credit Reporting Act is available for you to read during this application process.

I understand and agree that, if hired, my employment is for no definite period and may be terminated at any time without any prior notice.

I agree to the above terms

Des Moines Metro	Marshalltown	Boone	Fort Dodge	Corporate
12107 Stratford Drive Clive, Iowa 50325 Phone: 515-222-9995 Fax: 515-222-9985 1-877-4 CARE IA	104 W. Southridge Road Marshalltown, Iowa 50158 Phone: 641-752-5545 Fax: 641-753-3342 1-877-752-5545	811 Story Street Boone, Iowa 50036 Phone: 515-432-4430 Fax: 515-432-4449 1-888-432-4430	216 S. 8th Street Fort Dodge, Iowa 50501 Phone: 515-576-2273 Fax: 515-576-2989 1-877-760-0273	Phone: 515-222-2285 Fax: 515-225-6777

Copyright 2010, All rights reserved, Iowa Home Care, LLC