By submitting this application, I certify that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation, willful omission, false or misleading information is grounds for rejection of this application form, refusal to hire, withdrawal of an offer of Employment, or immediate discharge whenever discovered. You are authorized to conduct investigations, including verification of prior employment history and education. I also understand that employment is dependent upon receipt of acceptable employment references and satisfactory completion of pre-employment health screening which will include illicit drug testing and provision of documents required by the Immigration reform and Control Act of 1986. HAPPY HOME CARE LLC does not discriminate against any qualified person because of age, race, color, religion, sex, national origin, disability or sexual orientation. By submitting this application, I acknowledge that an offer of employment at HAPPY HOME CARE LLC should not be interpreted as an offer of continued or permanent employment.

Name *
Name
Current Address
Current Address
Preferred Phone
Preferred Phone
Date of Birth
Date of Birth
Date Available to Begin Work
Date Available to Begin Work
Which Shifts Can You Work
Education
Date Completed
Date Completed
List all professional licenses, registrations and certifications including state, number, date received, expiration date
Employment History
List your three most recent employers
Employer Address
Employer Address
Employment Begin Date
Employment Begin Date
Employment End Date
Employment End Date
Supervisor Phone Number
Supervisor Phone Number
Employer Address
Employer Address
Employment Begin Date
Employment Begin Date
Employment End Date
Employment End Date
Supervisor Phone Number
Supervisor Phone Number
Employer Address
Employer Address
Employment Begin Date
Employment Begin Date
Employment End Date
Employment End Date
Supervisor Phone Number
Supervisor Phone Number
References
Do not list family members as professional references
Reference #1
Reference #1
Phone Number
Phone Number
Reference #2
Reference #2
Phone Number
Phone Number
Reference #3
Reference #3
Phone Number
Phone Number