Careers – Ally Cares

Ally Care Employment Form

Ally Home Care - Employment Application

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

— Please read "Applicant Note” below.

— Complete all pages of this application.

— Print clearly. Incomplete or illegible applications may not be accepted.

— If more space is needed to complete any question, use comments section on the back.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment. Due to the nature of this business, all employees will undergo a background check.

PERSONAL INFORMATION

Today's Date

Position Applying for

Administrator

LPN

CNA

PCA

Companion Sitter

Position Applying for

Others (please specify

Full Name

Current Address

Previous Address (If you have not lived your current address for at least five years)

Emergency Contact

Cell Phone

Full Name

Driving License

Driving License #:

State Issued:

Exp. Date:

Make and Model of Vehicle:

Year of the Vehicle:

Do you currently have insurance coverage on your vehicle?

Insurance company

Policy expiration date:

Policy #

Have you ever submitted an application here before?

If yes, when?

Have you ever been employed at Ally Home Care before?

If yes, when?

How did you hear about our Ally Home Care?

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Availability

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

What date are you available to begin work?

Please tick all areas of availability:

Mornings

Afternon

Evenings

Overnights

Weekdays

Weekends

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferences

Please indicate all areas of the State in which you are willing to work:

DeKalb County

Fulton County

Gwinnett County

Other County

Please indicate the types of services which you are willing to provide:

Companionship

Housekeeping (dust/vacuum)

Errands/Shopping/Transportation*

Meal Preparation

Laundry/Ironing

Personal Care

Activities (games/crafts)

Medication Reminders

Dementia/Alzheimer’s Care

Are you willing to provide service to a client with a pet?

If yes, select which ones

Are you willing to provide service to a client that smokes?

JOB RELATED SKILLS

Do you have at least one year of experience working with or caring for senior or adults living with disability?

EDUCATION

Have you completed a High School Diploma?

Highest Level of Education?

Security

Have you had any moving traffic violations in the last 3 years?

If yes, please state

Have ever been convicted?

If yes, please state

Have you been charged/convicted of a felony and/or misdemeanor/or served time?

If yes, please describe

*Have you ever been a charged perpetrator or appeared on any child abuse / sex abuse registry in the last 5 years?

Do you consent to a federal background check? Mandatory for all caregiving positions

WORK HISTORY

Fill out completely and accurately.

Company

Date Employed

Job Title

State and City

Telephone

Supervisor

Company

Date Employed

Job Title

State and City

Telephone

Supervisor

Company

Date Employed

Job Title

State and City

Telephone

Supervisor

REFERENCES

Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional references.

Full Name

Phone Number

Best Time of The Day To Call

Relationship

Number of Years Known

Title

Full Name

Phone Number

Best Time of The Day To Call

Relationship

Number of Years Known

Title

Full Name

Phone Number

Best Time of The Day To Call

Relationship

Number of Years Known

Title

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Ally home care and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.