Anod, Inc.

"*" indicates required fields

Application for Employment

Full Name:*

Date:*

Address:*

Zip Code:*

Social Security Number:*

Are you at least 18 years of age?*

Yes

Date of Birth:*

Home Phone Number:*

Cell Phone Number:*

Email Address:*

Drivers License Number:*

State of Issue:*

Are you authorized to work in the United States on an unrestricted basis?*

Yes

EMPLOYMENT DESIRED

Position:*

Wage Desired:*

Date available to begin work:*

Hours preferred:*

Part-time

Full-time

How did you hear about us?*

What cities/locations are you willing to work in?*

Some sites may have pets. Are you willing to work in a home with pets?*

Yes

QUALIFICATIONS

Do you possess a valid Driver’s License?*

Yes

Have you received three or more traffic violations in the last 3 years?*

Yes

Has your driver’s license been suspended or revoked in the last 3 years?*

Yes

Have you ever been convicted of or pled guilty to a felony?*

Yes

Have you ever been convicted of or pled guilty to a crime involving the abuse, neglect or exploitation of a child or adult?*

Yes

Explain all YES answers:

Most positions with the Company require employees to transport individuals in a vehicle. Therefore, a valid driver’s license is crucial. Prior to hire, your driver’s license will be processed to ensure you are a valid and insurable driver.

EDUCATION

High School/GED:*

Yes

Degree:

Name of school:

Address:

Major:

Technical/Vocational:*

Yes

Degree:

Name of school:

Address:

Major:

College/University:*

Yes

Degree:

Name of school:

Address:

Major:

Other:*

Yes

Degree:

Name of school:

Address:

Major:

SPECIALIZED TRAINING, CERTIFICATION OF EXPERIENCE

First Aid:*

Yes

Expiration Date

Additional Comments

CPR & AED:*

Yes

Expiration Date

Additional Comments

MEDICATION ADMIN:*

Yes

Expiration Date

Additional Comments

BEHAVIOR SUPPORT:*

Yes

Expiration Date

Additional Comments

CRISIS INTERVATION:*

Yes

Expiration Date

Additional Comments

FEEDING/SWALLOWING TECHNIQUES:*

Yes

Expiration Date

Additional Comments

POSITIONING:*

Yes

Expiration Date

Additional Comments

TRANSFERRING:*

Yes

Expiration Date

Additional Comments

LIFTING:*

Yes

Expiration Date

Additional Comments

BLOODBORNE PATHOGENS:*

Yes

Expiration Date

Additional Comments

ASTHMA/BREATHING DIFFICULTY:*

Yes

Expiration Date

Additional Comments

NEBULIZER TREATMENTS:*

Yes

Expiration Date

Additional Comments

SEIZURE DISORDERS:*

Yes

Expiration Date

Additional Comments

CATHETER CARE:*

Yes

Expiration Date

Additional Comments

FEEDING TUBES:*

Yes

Expiration Date

Additional Comments

PARALYSIS (PARA/QUAD):*

Yes

Expiration Date

Additional Comments

List any license or certification you possess that is relevant to the position you are applying for:

The Company requires that all applicants submit four references, which may include: current or former employers, supervisors, teachers or other qualified to objectively evaluate your ability to work in the position for which you have applied. Please list reference information identified below. The Company will be contacting each reference listed.

PERSONAL REFERENCES:

We prefer to not use relatives as references.

Name:

Relationship to Applicant:

Daytime Phone Number:

Name:

Relationship to Applicant:

Daytime Phone Number:

Name:

Relationship to Applicant:

Daytime Phone Number:

WORK HISTORY

PLEASE COMPLETE WORK HISTORY FOR AT LEAST THE LAST 5 YEARS

If you are currently employed, may we contact your employer?*

Yes

Begin with current or most recent employer or position with employer:

1)

Employer:

Address:

Supervisor:

Phone Number:

Dates of Employment

Starting Date:

Ending Date:

Ending Wage:

Position:

Description of Job:

Reason for Leaving:

2)

Employer:

Address:

Supervisor:

Phone Number:

Dates of Employment

Starting Date:

Ending Date:

Ending Wage:

Position:

Description of Job:

Reason for Leaving:

3)

Employer:

Address:

Supervisor:

Phone Number:

Dates of Employment

Starting Date:

Ending Date:

Ending Wage:

Position:

Description of Job:

Reason for Leaving:

We are pleased you are interested in becoming a member of our Company. We are proud of our ex cellent reputation and the services we provide. We value diversity and want our work experience to be enjoyable. To help ensure a safe work environment and excellent services we carefully screen the background of all applicants. This screening may include as oral interview, as well as an investigation of your work history, driving record, application information, and reference check. Some service areas may also require an investigation of your background for any criminal conduct and an illegal drug screening.

APPLICANT DECLARATION OF UNDERSTANDING

PLEASE READ CAREFULLY AND SIGN BELOW

I understand that the Company may conduct an investigation of the information I have provided on the application and, as part of that investigation, may contact prior and/or current employers and references, among others, including but not limited to the following:

I authorize the Company to conduct this investigation and I release from all liability to hold harmless any person giving or receiving information about me relative to this investigation.

I understand that any falsification, misrepresentation or omission of information discovered as a result of this investigation may prevent my being hired or if hired, may subject me to the immediate termination of my employment with the Company.

I understand that this application process does not create an employment contract

I understand all employment at the Company is “at will.” This means, if the Company employs me, my employment is not for a specified or definite period of time and that I may be discharged from my position at any time, for any reason, with or without cause or prior notice.

I understand that the “at will” policy listed above cannot be changed or amended without a formal written employment agreement signed by myself and by a member of the Company management.

I declare that I have never committed nor been charged or convicted of any act of abuse, neglect, exploitation or fraud in relationship to dependent/vulnerable child or adult, within the past 10 years.

I declare that I have never knowingly violated any applicable rules or laws in any previous employ ment in a residential, healthcare or similarly related employment.

The Company is an equal opportunity employer and encourages diversity in employment. The Company makes all hiring decisions without regard to an applicant’s race, religion, sex, age, national origin, sexual orientation, disability or other protected classification under federal, state or local equal opportunity laws.

The use of illegal drugs is absolutely prohibited under Company policy. Where allowed by applicable law, the Company may require employees to submit to drug testing as a condition of continued employment.

By signing this application, I agree that I have read and understand the declarations listed above and I assert that all information given in this application is true.

Date:*

Signature:*

Stay connected:

Careers

Application for Employment

EMPLOYMENT DESIRED

QUALIFICATIONS

EDUCATION

SPECIALIZED TRAINING, CERTIFICATION OF EXPERIENCE

PERSONAL REFERENCES:

We prefer to not use relatives as references.

WORK HISTORY

PLEASE COMPLETE WORK HISTORY FOR AT LEAST THE LAST 5 YEARS

1)

Dates of Employment

2)

Dates of Employment

3)

Dates of Employment

APPLICANT DECLARATION OF UNDERSTANDING

PLEASE READ CAREFULLY AND SIGN BELOW

By signing this application, I agree that I have read and understand the declarations listed above and I assert that all information given in this application is true.

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