Employment application

Please fill out the following form and if there is a possible fit, we will contact you for an interview. Fill out as much as possible so we can process your application faster.

Start of Application

Please fill in all fields. You may be prompted for any missing information after clicking the submit button.

Personal
Full Name (First + Middle + Last)*
Drivers License Number*
Drivers License State
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Do you have the legal right to live and work in the U.S.?*
- Yes
- No
Other name(s) under which you have been previously employed
Names of friends or relatives employed in this organization
Have you ever applied to this organization before?*
- Yes
- No
If Yes, give date and position applied for
Have you ever been employed by this organization before?*
- Yes
- No
If yes, list dates of employment
Do you have any family, business, health, or social restrictions or obligations that would prevent you from performing the job responsibilities?*
- Yes
- No
Do you have any physical or mental condition or handicap which would endanger the health or safety of yourself and or others or that may affect your ability to perform the job(s) for which you are applying?*
- Yes
- No
If yes, please describe such condition or handicap.
Have you ever been convicted of a felony?*
- Yes
- No
If yes, list dates, offenses, and disposition.
Convictions are not an automatic disqualification from employment.
Will you comply with the safety work and attendance policies of our organization?*
- Yes
- No
Employment Interests
Position(s) Desired or Area of Interest:*
- Caregiver
- CNA
- Clerical Support
Date Available*
MM slash DD slash YYYY
Type of Employment You Are Seeking:*
- Part Time
- Temporary
Shifts You Can Work:*
- Select All
- Mon - Fri Morning
- Mon - Fri Afternoon
- Mon - Fri Evening
- Saturday & Sunday Morning
- Saturday & Sunday Afternoon
- Saturday & Sunday Evening
How will you get to work?*
How were you referred to our organization?*
- Advertisement
- Employee
- Other Company
- Agency
- Self
- Employment Service
Name of Referral Source:
Education/U.S. Military Service
Where did you attend high school & college? (Click the + button to add a new row)*
School Name & Address Major Years Completed GPA Degree/Diploma
Are you taking any educational course(s) presently?*
- Yes
- No
- I will be soon
If Yes or you will be soon, what and where?
Have you ever served in the U.S. Armed Services?
- Yes
- No
US Military Duties and special training
Rank held at discharge
References
List 1-3 people we may contact who are qualified to evaluate your capabilities. Do not include relatives. (Click the + button to add a new row)
Name Address Occupation Years Known
Employment History
Give employment record as completely as possible listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.
Company Name (Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Business Website
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Did you have another job before this one? Answer YES if more than one previous job.*
- Yes
- No
Company Name (Second Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Business Website
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Would you like to list another previous job?
- Yes
- No
Company Name (Third Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Business Website
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Would you like to list a 4th job?
- Yes
- No
Company Name (Fourth Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Dates Employed
From To
Job Title
Supervisors Name & Title
Type of Business
Business Website
Base Rate of Pay (Hour/Week/Month)
Start End
Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
I agree to a Drug Screening at the company's expense.*
- Yes
- No
I agree to a Criminal Background Check at the company's expense.*
- Yes
- No
Acknowledgement
Insert Your Legal Terms of Service Here
Digital Signature:

Printing your First Name + Middle Initial + Last Name will act as your digital signature.
Date
MM slash DD slash YYYY
Resume Upload (optional)
Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 16 MB.
If you have a resume you'd like to attach, please do so here. This is not required.
Would you like to add a cover letter?
- Yes
- No
Cover Letter (optional)
Max. file size: 16 MB.
Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below.
Section Break
Phone
This field is for validation purposes and should be left unchanged.

Premier Home Healthcare for Eastern Connecticut

CALL: (860) 535-6744

Employment application

Start of Application

Personal

Employment Interests

Education/U.S. Military Service

References

Employment History

Acknowledgement

Section Break

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School Name & Address	Major	Years Completed	GPA	Degree/Diploma

Name	Address	Occupation	Years Known

From	To

Start	End