Employment Application

Grosse Pointe Home Care

Employment Application
Please fill out the following application truthfully and to the best of your knowledge. Please allow up to 30 minutes to complete this Employment Application.

If you have questions, or the application does not load correctly, please contact our office at ‭(248) 599-1050‬.

*Please note your application will not complete until signed and submitted.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Are you 18 years or older?*

YesNo
Do you have transportation?*

YesNo
Some positions may require driving. Do you have a valid, unencumbered driver's license?*

YesNo
Date Available To Start:*

MonthDayYear
Date
Social Security No.:
Desired Salary/Hourly Rate:*
How far are you willing to travel for work? *

0 - 5 miles from home5 - 10 miles from home10 - 15 miles from home15 - 20 miles from home20 or more miles from home
Position Applied for:*
Do you have a Professional License or Certification?*
List State(s) where your Professional License and/or Certification is registered.
Are you able to perform the essential job functions associated with the job for which you have applied for without accommodation for a protected disability or religious practice? *Note: Timeliness and good attendance are essential functions for all jobs.**

YesNo
Is there an accommodation that would permit you to perform the function?

Yes - If yes, please list belowNo
Please state what the accommodation may be
Are you a citizen of the United States? *Note: Proof of identity and eligibility will be required upon employment*

YesNo
If no, are you authorized to work in the U.S.?

YesNo
Have you ever worked for this company?*

YesNo
If yes, when did you work for this company?
How did you hear about this employment opportunity?*

Employee Referral (please provide name below)IndeedCare.comGrosse Pointe Home Care WebsiteOther Source (please specify below)
Employee Referral Name

First NameLast Name
Please specify other source
Have you ever been convicted of a felony?*

YesNo
If yes, explain:
Are you currently under a legal agreement such as a non-compete agreement or a settlement agreement, which might prevent you from working at for another company or from rendering services to specific clients?*

YesNo
Education
High School / GED: Name
Address
Have you received a high school diploma or its equivalent? Yes No
Diploma:
College: Name
Address
Did you graduate? Yes No
Degree:
Other: Name
Address
Did you graduate? Yes No
Degree/Certificate:
References

Please list three professional references.
Full Name:First Name   Last Name Position/Title   Type a label
Company:   Type a label
Address:   Street Address City State   Zip
Phone    Phone Number
Full Name:First Name   Last Name Position/Title   Type a label
Company:   Type a label
Address:   Street Address City State   Zip
Phone    Phone Number
Full Name:First Name   Last Name Position/Title   Type a label
Company:   Type a label
Address:   Street Address City State   Zip
Phone    Phone Number
Previous Employment
Company:   Name   Phone:   Phone Number
Supervisor:   First Name   Last Name
Address:   Street Address   City State   Zip
Job Title:
Starting Salary $      Ending Salary $
Responsibilities:
From:   Date   To:   Date
Reason for Leaving:
May we contact your previous supervisor for a reference?   Yes   No
Company:   Name   Phone:   Phone Number
Supervisor:   First Name   Last Name
Address:   Street Address   City State   Zip
Job Title:
Starting Salary $      Ending Salary $
Responsibilities:
From:   Date   To:   Date
Reason for Leaving:
May we contact your previous supervisor for a reference?   Yes   No
Military Service
Branch From:Date   To:   Date
Rank at Discharge:
Type of Discharge:   Type a label
If other than honorable, explain:   Type a label
Resume

You may submit your resume here.
Cancelof
Disclaimer and Signature

*Please note your application will not complete until singed and submitted.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature*

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Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Grosse Pointe Home Care

Education

References

Previous Employment

Military Service

Disclaimer and Signature