Careers APPLICATION FOR EMPLOYMENT Oasis of Love Home Care is an equal Opportunity Employer. Employment offers are made on basis of qualifications, and without regard of race, sex, religion, national or ethnic origin, disability, age, veteran status or sexual orientations. Please complete this employment application form for consideration. We strongly suggest proof-reading your application before clicking the submit button. We look forward to working with you!PERSONAL INFORMATIONFirst Name* Middle Name Last Name* Other names Used Address* City* State / Province*IndianaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPostal / Zip Code* Email Address* Phone Number*Are you legally entitled to work in the U.S.?* Yes No Have you ever been convicted of a felony* Yes No Please Explain Are you 18 Years of age or older* Yes No Current age Are you currently employed?* Yes No May we contact this employer?* Yes No Company Name Company Address Current Job Title Current Job Department Have you ever been employed by Oasis of Love Home Care?* Yes No Date from MM slash DD slash YYYY Date To MM slash DD slash YYYY Reason for leaving Are you related to any current Oasis of Love Home Care Employee?* Yes No Their name Their relationship to you If required for position, do you have a valid Driver License?* Yes No State issued, License # & Expiration date If required for position, do you have a valid Proof of insurance* Yes No Insurance Company & ID # How did you learn about this employment opportunity at Oasis of Love Home Care? Check all that apply* Job Bulletin posting / walk Depart. Of labor Website Referral by employee Other POSITIONPosition Applying for* CNA HHA CAREGIVER Administration Office | Clerical Date Available* MM slash DD slash YYYY Applying For* Part-Time Full-Time Temporary Days Evenings Nights Days Available to work* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?* Yes No Please Explain EDUCATION AND TRAININGSchool NameSchool NameCity | StateDates Attended Month/Year (From)Dates Attended Month/Year (To)Did you Graduate?If no, # of years left to graduateDegree receivedMajor Add Removeclick the + to add EducationOther credentials – Licenses | Certifications or professional affiliations, etc., which are relevant to the job(s) for which you are applying.Type of License | certificationsLicense and | Certification # and State IssuedExpiration Date Add RemoveSpecial Skills you have to offer for this positionEMPLOYMENT HISTORY (Begin with Most Recent Employment)Employer #1 (Company Name)* Job Title & Duties* From* MM slash DD slash YYYY To* Supervisor's Name* Phone*Address* Reason for leaving May We Contact This Employer? Yes No Employer #2 (Company Name) Job Title & Duties From MM slash DD slash YYYY To MM slash DD slash YYYY Supervisor's Name PhoneAddress Reason for leaving May We Contact This Employer? Yes No Employer #3 (Company Name) Job Title & Duties From MM slash DD slash YYYY To MM slash DD slash YYYY Supervisor's Name PhoneAddress Reason for leaving May We Contact This Employer? Yes No REFERENCES: Give names of three Persons NOT related to you. Two of your References MUST be supervisory or Professional*NamePhone #AddressOccupation Add RemoveThe information on this application is true, and accurate to the best of my knowledge.* The information on this application is true, and accurate to the best of my knowledge.*Full Name* SignatureDate* MM slash DD slash YYYY APPLICATION DISCLAIMERSAuthorization to Release Information I have applied for a position with Oasis of Love Home Care. I have been requested to provide information for their use in reviewing my background and qualifications. Therefore, I hereby authorize the investigation of my past and present work character, education, military and employment qualifications. I authorize the release of my information to Oasis of Love Home Care whether the information is of record or not, and I do hereby release all persons, agencies, firms, companies, etc., from any damages resulting from providing such information. This authorization is valid for 180 days from the date below. Please keep this copy of my release request in your files.SignatureName Date MM slash DD slash YYYY Consent for Drug/ Alcohol Screen TestingIf you are offered and accept employment with Oasis of Love Home Care, in the interest of safety for all concerned, you will be required to take a urine test for drug and / or alcohol screening. I have been fully informed of the reason for this urine test for drug and/or alcohol screening. I fully understand what I am being tested for, the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to my potential employer and become part of my record. If this test is positive and l am not hired. I understand that I will be given the opportunity to explain the results of this test. I hereby authorize these test results to be released to: Oasis of Love Home CareSignatureName Date MM slash DD slash YYYY Oasis of Love Home Care -IS AN EQUAL OPPORTUNITY EMPLOYER Applicant Acknowledgement I certify that the information in this application is accurate, current and complete. I understand that incorrect statements or omission may result in disqualification from further consideration or termination of employment. I authorize Oasis of Love Home Care to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision. I authorize Oasis of Love Home Care to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize Oasis of Love Home Care to disclose any of my performance Appraisals, disciplinary record, or skills test for the same purpose as above. I release Oasis of Love Home Care and any individual or entity providing information to Oasis of Love Home Care from all liability for any damages from the disclosure of this information. I also understand and agree that: Passing a medical examination and / or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated. I may not be hired, or if hired, employment may be terminated. Subject to applicable state laws, Oasis of Love Home Care reserves the right to conduct drug screening and testing for reasonable suspicion at anytime during employment and as a pre-employment requirement. Any violation of this policy shall result in an applicant not being hired or an adverse employment action up to including immediate termination. Oasis of Love Home Care has the right to change this policy at any time as it requires. I understand that nothing contained in this employment application or in granting of an interview creates an employment contract between Oasis of Love Home Care and me for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable at will”, that I will have the right to terminate my employment at any time. I understand that should I become employed by Oasis of Love Home Care my work assignment, schedules and / or work locations are subject to change according to the needs of the business and the clients of Oasis of Love Home Care. SignatureName Date MM slash DD slash YYYY