Careers Form

* Required Information

AMERICAN BEST CARE LLC APPLICATION FOR EMPLOYMENT

Company Name *

Date

Please Answer All Questions. Resumes Are Not A Substitute For A Completed Application.

We are an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state, or local laws.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE.

Applicant Name *

Position Applied For (list only one)

Telephone Number *

Alternate or Cellular Telephone Number

Present Address *

City *

State *

Zip *

How long have you lived in PA: Years / Months

Email Address *

If under the age of 18, can you produce the necessary work certificate at the time of employment?

Yes

Type of employment desired

Full-time

Part-time

Specify Hours

Are you willing to work overtime?

Yes

Date on which you can start work if hired

Have you previously applied for employment with this Company?

Yes

Have you ever been employed by this Company?

Yes

If applicable, below list any other names by which you have been known which may be necessary to allow us to confirm your work and educational record. For example, change of name, use of an assumed name, nickname, etc.

EDUCATION

Highschool

Address

City

State

Course of Study or Major

Graduate?

Yes

Number of Years Completed

Honors Received

College

Address

City

State

Course of Study or Major

Graduate?

Yes

Number of Years Completed

Honors Received

Graduate or Professional

Address

City

State

Course of Study or Major

Graduate?

Yes

Number of Years Completed

Honors Received

CERTIFICATIONS AND TRAINING

Certified Nurse Assistant (CNA)?

Yes

CPR Certification?

Yes

First Aid Certification?

Yes

Home Health Health HHA/Direct Care Care License?

Yes

Any other specialized caregiving training?

BACKGROUND INFORMATION

Have you ever been convicted of felony?

Yes

Explain

Do you have any physical or mental conditions that may affect your ability to perform this Job?

Yes

Explain

WORK EXPERIENCE

Please list the names of your present and/or previous employers in chronological order with present or most recent employers listed first. Provide information for at least the most recent ten (5) y id on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment. Do not answer "See Resume"

Employer 1

Name

Address

Type of Business

Telephone

Dates Employed (From)

Dates Employed (To)

Job Title

Duties

Supervisor's Name

May we contact?

Yes

Reason for Leaving

Employer 2

Name

Address

Type of Business

Telephone

Dates Employed (From)

Dates Employed (To)

Job Title

Duties

Supervisor's Name

May we contact?

Yes

Reason for Leaving

What will this employer say was the reason your employment was terminated?

Were you ever disciplined?

Yes

Have you ever been terminated or asked to resign from any job?

Yes

Has your employment ever been terminated by mutual agreement?

Yes

REFERENCES

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

Reference 1

Name

Position

Company

Work Relationship

Telephone

Reference 2

Name

Position

Company

Work Relationship

Telephone

EMERGENCY CONTACT

Please list the names of personal references (not previous employers or relatives) who you know that we may contact.

Contact Person 1

Name

Occupation

Address

Telephone

Number of years known

Contact Person 2

Name

Occupation

Address

Telephone

Number of years known

DRIVING INFORMATION

Complete only if driving is an essential function of the job for which you are applying.

Do you have a current valid driver's license?

Yes

If you do not have a driver's license for the state in which you currently reside, why not?

Has your license ever been suspended or revoked?

Yes

Do you have personal Vehicle insurance?

Yes

Have you ever been denied personal Vehicle insurance or has it ever been terminated or suspended?

Yes

Please list all moving traffic violations in the last five (5) years

Offense

Date

Location

Comments

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver's license for the state in which I reside and automobile liability insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of the location, pursuant to the Company's policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking of alcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company's policies and applicable federal, state, and local law.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to sign a confidentiality, restrictive covenant, and/or conflict of interest statement.

I certify that all the information on this application, my resume, or any supporting documents I may present during any interview is and will be complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information may result in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANY PROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT OR STATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE OR REPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANY APPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACT SIGNED BY THE PRESIDENT OF THE COMPANY.IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THE COMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONS AT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I am seeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the background investigation which may be permitted by federal, state and/or local law. If applicable and allowed by law, I will receive separate written notification regarding the Company's intent to obtain "consumer reports."

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. I hereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to the Company or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I may have as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and its representative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, I authorize the company to provide truthful information concerning my employment to future employers and hold the company harmless for providing such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to be legally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to work in the United States.

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

By signing this application,I the applicant acknowledge and agree that American Best Care LLC shall not be held liable for any increased liability damages ,losses or expenses that may arise out of or in connection with my employment,except for those resulting from gross negligence or willful misconduct by the Employer.This includes but not limited to any personal injury,property damage,or third party claims that may occur during the course of the employment.

I understand that the employer provides appropriate training and resources to ensure a safe working environment and that it is my responsibility to adhere to all safety protocols and guidelines provided by the Employer.I also acknowledge that i am responsible for maintaining my own health and safety while performing my duties and reporting any unsafe conditions to the employer.

DO NOT SIGN UNTIL YOU HAVE READ ALL OF THE INFORMATION CONTAINED IN THE APPLICATION.

Applicant Signature *

Clear

Date

If the applicant is a minor, the foregoing release and consent must be signed by the applicant's parent or legal guardian. Signature by the applicant's parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant's legal guardian.

Parent or Legal Guardian *

Clear

Date

THIS APPLICATION MAY NOT BE SUFFICIENT FOR ALL INDUSTRIES OR APPROPRIATE FOR USE IN ALL LOCALITIES.