Employment Application Form

PLEASE PRINT CLEARLY AND ANSWER ALL Questions?

PLEASE, SHOW TIMES WHEN YOU’RE AVAILABLE TO WORK:

Day-time Hours

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Night-time Hours

Live-In

Yes

No

Have you ever applied with Simplicity HealthCare Management before?

BACKGROUND

Yes

No

Have you ever been convicted of a crime?

(PLEASE NOTE: A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM EMPLOYMENT)

Yes

No

Do you currently use any controlled substances (including marijuana)?

Yes

No

. Do you smoke?

Yes

No

*Are you willing to work in a smoker’s home?

Yes

No

Do you have any conditions that limit your ability to perform the job as

listed in the Job Description?

Yes

No

Do you have a valid Georgia driver’s license?

Yes

No

Do you have your own car?

Yes

No

*Will you transport a client?

NOTE: If hired you are required to provide proof of insurance to the Agency

LOCATION PREFERENCES: i.e Atlanta, Dekalb, Clayton etc.

LICENSING INFORMATION

Educational Background

School Name

City, State

Major

No. of yrs Attended

Graduated?

High School

Vocational/ Technical

College/ University

List languages spoken

EMPLOYMENT HISTORY

List employment for the past five years, with the most recent job first

Yes

No

May we contact your current employer?

Yes

No

May we contact your current employer?

Yes

No

May we contact your current employer?

Personal References

Please list 3 personal references below. These references may be anyone who knows you personally, that is not your family member. Previous employers will be called for professional references. If you do not have at least 3 professional references, please provide additional names for personal references. These can be co-workers, volunteer organizers, your Pastor or teachers.

I hereby authorize Simplicity HealthCare Management to request and receive from all prior employers within one (1) year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I authorize the references I have listed to provide all information regarding my suitability for employment. I hereby release all persons from any liability for any damages that may result from giving information to Simplicity HealthCare Management. I also authorize investigation of all statements contained in this application. I understand and agree that employment with Simplicity HealthCare Management is at-will. That is, it may be terminated at the will of either employer or the employee at any time, with or without notice and with or without cause or reason.

Signature ofApplicant

Your content has been submitted

Employment Application Form

Day-time Hours

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Night-time Hours

Live-In

Have you ever applied with Simplicity HealthCare Management before?

​

Have you ever been convicted of a crime?

(PLEASE NOTE: A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM EMPLOYMENT)

Do you currently use any controlled substances (including marijuana)?

. Do you smoke?

*Are you willing to work in a smoker’s home?

Do you have any conditions that limit your ability to perform the job as

listed in the Job Description?

Do you have a valid Georgia driver’s license?

Do you have your own car?

*Will you transport a client?

NOTE: If hired you are required to provide proof of insurance to the Agency

LOCATION PREFERENCES: i.e Atlanta, Dekalb, Clayton etc.

School Name

City, State

Major

No. of yrs Attended

Graduated?

High School

Vocational/ Technical

College/ University

List languages spoken­­­­­­­­­­­­­­­­­­­­­­­­­­­

List employment for the past five years, with the most recent job first

May we contact your current employer?

May we contact your current employer?

May we contact your current employer?

List languages spoken