Equal Employment Opportunity (EEO)

Hayath Senior Care, LLC is an Equal Opportunity Employer. All qualified applicants will be considered for positions without regard to race, color, religion, gender, national origin, age, sexual orientation, gender identity and/or expression, martial or veteran status, or the presence of a physical or mental disability that is not job-related. Applicants are evaluated on the basis of ability, experience and the requirements of the job.

Please print and answer all questions thoroughly

Position you are seeking:

Application Date:

How did you Hear about this Position?

Personal Information

Full Legal Name:

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email:

Phone (Home) :

Phone (Cell) :

Gender:

Male

Female

Language(s):

Date of Birth:

Employment Desired

Type of Employment :

Full Time

Part Time

Temporary

Date Available for work:

Are you able to be legally employed in United States?

Yes

Have you previously been employed by Hayath Senior Care, LLC

Yes

If yes, please provide the date of you employment:

Position:

Do you have a valid Drivers License?

Yes

If hired, do you have reliable means of transportation to work?

Yes

If hired, would there be restriction on travel if required?

Yes

Employment History

List all present and past employers, starting with you most recent employer.

Employer:

First Last

Telephone:

Date Employed (From)

Date Employed (To)

Address

Street Address City State / Province / Region ZIP / Postal Code

Job Title:

Immediate Supervisor:

First Last

Reason(s) for Leaving:

Describe Duties and Responsibilities:

Employer:

First Last

Telephone:

Date Employed (From)

Date Employed (To)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Job Title:

Immediate Supervisor:

First Last

Reason(s) for Leaving:

Describe Duties and Responsibilities:

Employer:

First Last

Telephone:

Date Employed (From)

Date Employed (To)

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Job Title:

Immediate Supervisor:

First Last

Reason(s) for Leaving:

Describe Duties and Responsibilities:

Education & Training

Name / Location

Course

Year Completed

Type of Degree

Name / Location

Course

Year Completed

Type of Degree

Name / Location

Course

Year Completed

Type of Degree

Name / Location

Course

Year Completed

Type of Degree

List any certifications, trainings, or other education not listed above that may help you qualify for this position:

References

List below three persons not related to you who have knowledge of your work performance within the last 5 years

Name

First Last

Occupation:

Company:

Years Known:

Phone #:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name

First Last

Occupation:

Company:

Years Known:

Phone #:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name

First Last

Occupation:

Company:

Years Known:

Phone #:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Agreement & Authorization

Please read the following statements.

I certify that the above information is accurate and true to the best of my knowledge. In the event of my employment, I understand and agree that false or misleading information given in my application or interview(s) may result in discharge.

I understand that this application is for informational purposes only and does not constitute an offer of employment or an employment contract. If an employment relationship is later established, I understand my right to resign at anytime for any reason. I also understand that this company may also terminate my employment at any time, for any reason not prohibited by law.

I authorize Hayath Senior Care, LLC to inquire and investigate into my employment, educational, professional, criminal and other background as needed to verify the information on this application and research my qualifications for this position.

I hereby release Hayath Senior Care, LLC from all liability that might result from such investigation into my background.

I hereby acknowledge that I have read and agree to the above statements

Signature

Date

FOR OFFICE USE ONLY

REMARKS

Interviewed by:

First Last

Date

APPROVAL

Position:

Hiring Date:

President / Manager:

First Last

CAPTCHA

Careers

Equal Employment Opportunity (EEO)

Please print and answer all questions thoroughly

Personal Information

Employment Desired

Employment History

Education & Training

References

Agreement & Authorization

FOR OFFICE USE ONLY

APPROVAL

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