Careers Form

* Required Information

PERSONAL INFORMATION

Date Today *

First Name *

Middle Initial

Last Name *

Preferred Name/Nickname

Street Address

Apartment Number

City

State

Zip Code

Home Phone

Alternate/Work Phone

Email Address

Social Security Number

EMPLOYMENT DETAILS

Are you interested in:

Full Time

Part Time

Temporary

What schedule would you prefer?

Weekdays

Weekends

Evenings

Nights

How did you hear about the position?

Classified Ad

Friend

Radio

Internet

Name of Friend

Desired Pay

Hourly Pay (Minimum)

Annual Pay (Minimum)

Annual Pay (Desired)

When are you able to start to work?

In what local area do you prefer to work?

Position Desired

I hereby authorize Metro 1 Home HealthCare Services Inc. to request and receive from all prior employers within one year of the dare of this application, in any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination

Sign *

Date *

Metro 1 HOME HEALTHCARE SERVICES INC. is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion,sex national origin, disability, age, or military or veteran status in accordance with federal law. In addition, METRO 1 HOME HEALTHCARE SERVICES INC. complies with applicable state and local laws governing non-discrimination in employment in every jurisdiction in which it maintains facilities. METRO 1 HOME HEALTHCARE SERVICES INC. also provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws.

Are you authorized to work in the United States?

Yes

Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, Metro 1 HOME HEALTHCARE SERVICES INC. will verify the status of every individual offered employment with the Company,. In this connection, all offers of employment are subject to verification of the applicant's identity and employment authorization, and it will be necessary for you to submit such documents as are required by the law to verify your identification and employment authorization.

Are you under 18 years of age?

Yes

Can you furnish a work permit

Yes

Are you capable of performing the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes

EMPLOYMENT HISTORY

Company Name

Your Position and Title

From

Supervisor's Name Title and Position

Supervisor's Telephone Number

Number and Street

City

State

Zip Code

Type of Business

Starting Pay ($)

Final Pay ($)

Telephone Number

Termination

Voluntary

Involuntary

Reason

Briefly Describe your major duties and reasons for termination

Company Name

Your Position and Title

From

Supervisor's Name Title and Position

Supervisor's Telephone Number

Number and Street

City

State

Zip Code

Type of Business

Starting Pay ($)

Final Pay ($)

Telephone Number

Termination

Voluntary

Involuntary

Reason

Briefly Describe your major duties and reasons for termination

Company Name

Your Position and Title

From

Supervisor's Name Title and Position

Supervisor's Telephone Number

Number and Street

City

State

Zip Code

Type of Business

Starting Pay ($)

Final Pay ($)

Telephone Number

Termination

Voluntary

Involuntary

Reason

Briefly Describe your major duties and reasons for termination

EDUCATION

Highschool or Prep

Name of School

Address of School

Did you graduate?

Yes

Type of Diploma or Degree

College

Name of School

Address of School

Did you graduate?

Yes

Type of Diploma or Degree

College or Graduate

Name of School

Address of School

Did you graduate?

Yes

Type of Diploma or Degree

Other

Name of School

Address of School

Did you graduate?

Yes

Type of Diploma or Degree

Professional Liability Insurance

Company

Effective Date

Expiration Date

Company

Effective Date

Expiration Date

Professional Licenses

Type of License

State Granting License

License Number

Expiration Date

Type of License

State Granting License

License Number

Expiration Date

References: (please list three professional references)

Name

Relationship

Company

Phone/Alternative Phone

Name

Relationship

Company

Phone/Alternative Phone

Name

Relationship

Company

Phone/Alternative Phone

Please read carefully

I have submitted the attached form to the company for the purpose of obtaining employment. I acknowledge that the use of this form, and my filling it out, does not indicate that any positions are open, nor does it obligate the company to further process my application.

My signature below attests to the fact that the information that I have provided on my application, resume, given verbally, or provided in any other materials, is true and complete of the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the Company's employ.

I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with the Company in the position I am seeking.

I understand that this application is not an employment contract for any specific length of tme between the Company and me, and that in the event I am hired, my employment will be "at will" and neither the Company or I can terminate my employment with ot without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy, and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process affecting its employees.

References: I hereby authorize the company and its agents to makes such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquiries connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form. Furthermore, I authorize the company and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications.

Temporary/Contract Employment: If employed as a temporary or contract employee, I understand that I may be an employee of the company and not of any client. If employed, I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. I further understand that contract will exist between the company and each client to whom I may be assigned which will require the client to pay a fee to the company in the event that I accept direct employment by a client (or by referral of the client to any subsidiary or affiliated company), either for a permanent, temporary (including assignments through another agency), or consulting positions during my assignment or after my assignment has ended.

Name *

Date *