RHC EMPLOYMENT APPLICATION | Reward Home Care

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Employment Application

PERSONAL INFORMATION

Full Name (First, Middle, Last) *

Street Address*

City & State*

ZIP Code*

Email*

Phone*

Date Available*

Desired Pay ($/hr or Salary)*

Position Applied For *

Employment Type Desired:*

Full-Time

Part-Time

Seasonal

Per Diem

EMERGENCY CONTACT FORM

EMERGENCY CONTACT 1

Full Name:*

Relationship to Employee:*

Phone

EMERGENCY CONTACT 2

Full Name:*

Relationship to Employee:*

Phone

EMPLOYMENT ELIGIBILITY

Are you legally eligible to work in the United States?*

Yes

No

Have you ever worked for Reward Transportation Services before?*

Yes

No

If yes, start & end dates:*

Have you ever been convicted of a felony?*

Yes

No

If yes, please explain: *

EDUCATION

High School Name *

City / State *

Graduated?*

Yes

No

College / University

City / State

Degree Earned

Other School / Certification

City / State

Degree / Certificate

PREVIOUS EMPLOYMENT

Employer 1:

Company Name*

Address *

City*

State*

ZIP Code*

Supervisor Name*

Phone

Email

Job Title*

Starting Pay *

Ending Pay*

Dates Employed (From → To)*

Reason for Leaving*

Employer 2:

Company Name*

Address *

City*

State*

ZIP Code*

Supervisor Name*

Phone*

Email*

Job Title*

Starting Pay *

Ending Pay*

Dates Employed (From → To)*

Reason for Leaving*

PROFESSIONAL REFERENCES (NON-FAMILY)

Reference 1 — Full Name*

Company / Organization*

Title / Relationship*

Phone*

Email*

Reference 2 — Full Name*

Company / Organization*

Title / Relationship*

Phone*

Email*

MILITARY SERVICE

Are you a veteran?

Yes

No

Branch

Rank at Discharge

Type of Discharge

Service From

Service To

BACKGROUND CHECK CONSENT

If asked, are you willing to consent to a background, MVR, and drug screening check?

Yes

No

Applicant Certification & Disclaimer

I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that if I am hired and it is later discovered that I provided false or misleading information, I may be discharged. I authorize investigation of all statements contained in this application and authorize all former employers and references to release information concerning my previous employment. Reward Home Care is an Equal Opportunity Employer.

Applicant Signature

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18 Campus Blvd - Suite 100 - Newtown Square, PA 19073

(215) 701-6675 - www.rewardcares.org

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