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2531 Briarcliff Rd, Suite 216
Atlanta, Georgia 30329
Tel: 678.448.4191
Fax: 470.632.0660

      

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Employment Application

Helping Hands Home Care Employment Application
  1. Personal Information

  2. First Name(*)
    Please provide your First Name
  3. Last Name(*)
    Please provide your Last Name
  4. Last 4 Digits of SSN(*)
    Please provide the last 4 digits of your SSN
  5. Driver's License Number
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  6. Drivers License State
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  7. Present Address(*)
    Please provide your Present Address
  8. Permanent Address (if different from above)
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  9. Telephone(*)
    Please provide your Phone Number
  10. Email Address(*)
    Please provide your email address
  11. If you are under 18, can you furnish a work permit?
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  12. Employment Desired




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  13. Position Desired
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  14. Desired Start Date

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  15. Desired Salary
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  16. Are you currently employed?
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  17. If yes, may we contact your current employer?
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  18. Have you ever applied to this company before?
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  19. If yes, please state where and when.
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  20. Are you on layoff and subject to recall?
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  21. Will you travel if required?
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  22. Will you relocate if required?
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  23. Are you able to meet the attendance requirements of this position?
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  24. Have you ever been bonded?
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  25. Have you been convicted of a felony in the past 7 years?
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  26. Such conviction may be relevant if job related, but does not bar you from employment. If yes – explain.
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  27. Education

  28. Academic - Currently Attending

  29. Name and Location of School
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  30. Number of Years Completed
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  31. Did you Graduate?
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  32. Subjects Studied
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  33. Academic - Last Completed

  34. Name and Location of School
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  35. Number of Years Completed
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  36. Did you Graduate?
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  37. Subjects Studied
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  38. Trades of Business - Currently Attending

  39. Name and Location of School
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  40. Number of Years Completed
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  41. Did you Graduate?
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  42. Subjects Studied
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  43. Trades of Business - Last Completed

  44. Name and Location of School
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  45. Number of Years Completed
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  46. Did you Graduate?
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  47. Subjects Studied
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  48. Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with this company.
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  49. Professional Licenses

  50. Professional License Number 1
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  51. Professional License Number 2
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  52. Employment History

  53. Employment 1

  54. Dates: From - To
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  55. Employer Name
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  56. Employer Address
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  57. Salary
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  58. Job Title
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  59. Reason for Leaving
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  60. Employment 2

  61. Dates: From - To
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  62. Employer Name
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  63. Employer Address
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  64. Salary
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  65. Job Title
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  66. Reason for Leaving
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  67. Employment 3

  68. Dates: From - To
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  69. Employer Name
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  70. Employer Address
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  71. Salary
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  72. Job Title
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  73. Reason for Leaving
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  74. References

    Please provide the names of three persons, not related to you, whom you have known at least 1 year.
  75. Reference 1

  76. Reference Name(*)
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  77. Reference Address(*)
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  78. Reference Phone(*)
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  79. Years Acquainted(*)
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  80. Reference 2

  81. Reference Name(*)
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  82. Reference Address(*)
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  83. Reference Phone(*)
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  84. Years Acquainted(*)
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  85. Reference 3

  86. Reference Name(*)
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  87. Reference Address(*)
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  88. Reference Phone(*)
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  89. Years Acquainted(*)
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  90. Foreign Languages

    List any foreign language(s) and check the box that best describes your skill level.
  91. Language 1
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  92. Skill Level



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  93. Language 2
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  94. Skill Level



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  95. Emergency Contact

    In case of emergency please notify:
  96. Emergency Contact Name
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  97. Relationship
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  98. Emergency Contact Address
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  99. Emergency Contact Phone
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  100. Conditions of Employment

    Please read carefully the conditions of employment below and initial below indicating that you have read and understood them.
  101. 1. Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

    2. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

    3. I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

    4. The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, State or Federal law.

    5. Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation and failing settlement in mediation, to binding arbitration. Unless otherwise agreed a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

    6. This application is current for 90 days. At the conclusion of this time if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.
  102. Initial(*)
    Please Initial the Conditions of Employment
  103. Upload Resume

    If you have a resume, please upload it now. Please submit resume either as a PDF or DOC file. Your file should be no greater than 2MB.
  104. Upload Resume
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  105. Signature (Type your full name)(*)
    Please sign your name
  106. Date(*)

    Please enter today's date.
  107. Please enter security code(*)
    Please enter security code   RefreshPlease enter correct security code shown.
  108.   

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