If you are considered for a position, we may contact your references and would ask that you notify them in advance. Please do not list relatives or family/relations.

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

• Please read "Applicant Note” below.
• Complete all pages off this application.
• Print clearly. Incomplete or illegible applications may not be accepted.
• If more space is needed to complete any question, use comments section on the back.
• Application will be valid for 60 days.

Applicant Note: This application form is intended for use in evaluating your qualifications for employment with us , an independently owned and operated Home Instead franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.

As a condition of employment, all employees must be "Bondable".

List states and counties of residence for the past seven (7) years:

County:

State:

County:

State:

County:

State:

County:

State:

* Have you had any moving traffic violations?

Yes   No

* If yes, please describe:

* As of the date of this authorization, do you have any pending criminal charges against you?

Yes   No

* If yes, please explain:

* Have you ever received deferred adjudication, probation, or community supervision for any offense?

Yes   No

* If yes, please explain:

* Have you been convicted of a felony or misdemeanor in the past seven (7) years?

Yes   No

If Yes, please describe below:
(Conviction will not necessarily disqualify applicant from employment. The recency, severity, and pertinence of the conviction to the job will all be considered.)

Incident	City/State	Result

Please complete all four references (two professional/two personal). Your application will not be considered unless two references are provided. Since we will contact these references, please notify them in advance. .

Professional References

Full Name	Phone Number	Email	Relationship	Number of Years Known
*	*	*	*	*
*	*	*	*	*

Personal References

Full Name	Phone Number	Email	Relationship	Number of Years Known
*	*	*	*	*
*	*	*	*	*

I certify that I have read and understand the applicant note above and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application process may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I also understand that the use of illegal drugs is prohibited when carrying out my job responsibilities. I am willing to submit to drug screening to detect the use of illegal drugs prior to and during employment, as allowed under applicable law.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT.

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date: