Employment Application

Name:*

Your First NameYour Last Name
Application Date*

MonthDayYear
HourMinutesAM/PM Option
None of the information you place in this document will be released to outside parties. This document and all information within it is secured and compliant with all current HIPPA regualtions.

PLEASE ENTER YOUR INFORMATION IN ENGLISH ONLY

REFERENCES
By filling out the information below, I hereby authorize Unique Aid's ability to contact the references listed:
Reference 1 Name:*
Relation to Applicant:*
Phone:*
Reference 2 Name:*
Relation to Applicant:*
Phone:*

PREFERENCES AND AVAILABILITY

Availability*

	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
Morning (7a-12p)
Afternoon (12p-5p)
Evening (5p-10p)
Overnight (10p-7a)

Maximum hours you want to work per week:*
Minimum hours you want to work per week:*
How many minutes are you willing to travel from your home?*
Are you willing to perform personal care for males older than 14 years old?*

YesNo
Are you available for live-in cases?*

YesNo
Any pet restrictions or allergies?*

YesNo
If "yes" please specify:*

I have completed this form to the best of my ability, and I understand that misrepresentation or falsification of facts may be cause for prolongation of the application process or rejection of employment. I give permission to have Unique AID company send me SMS for any communication related to this application or my employment.
Please confirm:*

YesNo
Signature*

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