Date: 4/18/2014

Application Form

Seniors Helping Seniors

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1. What municipality do you live in?  
     
2. Can you provide documentation of a driver's license and auto insurance? (required)  
     
3. Driver's License Expiration Date:  
     
4. Auto Insurace Expiration Date:  
     
5. Date available to start work? (required)  
     
6. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
7. If yes, please explain.  
     

Section 2 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you a U.S. citizen? (required)  
     
2. If you are not a U.S. citizen, please indicate VISA type and number.  
     
3. Are you authorized to work in the U.S.? (required)  
 
 
 
 

Section 3 - Education

Number Question Effective Date Expiration Date
1. Name of High School: (required)  
     
2. Location of High School: (required)  
     
3. Did you graduate? (required)  
     
4. Years Attended (From/To): (required)  
     
5. Additional Education (vocational, undergraduate, etc.)  
     
6. If yes, please list the name of the school and years attended (From/To)  
     

Section 4 - Other Training/Pertinent Information

Number Question Effective Date Expiration Date
1. Certifications/Licenses:  
     
2. List unique skills and abilitiees acquired independently:  
     
3. List your hobbies:  
     
4. List your favorite activities:  
     
5. List any self-improvement initiatives:  
     
6. List any volunteer work you have done:  
     
7. Why do you wnat to work for SHS?  
     

Section 5 - Current Employment

Number Question Effective Date Expiration Date
1. Current Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Describe Your Responsibilities:  
     
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving:  
     
14. May we contact?  
     

Section 6 - Employment History

Number Question Effective Date Expiration Date
1. Last Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Describe Your Responsibilities:  
     
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving:  
     
14. May we contact?  
     

Section 7 - Reference 1

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Relationship: (required)  
     
3. Phone: (required)  
     

Section 8 - Reference 2

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Relationship: (required)  
     
3. Phone: (required)  
     

Section 9 - Reference 3

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Relationship: (required)  
     
3. Phone: (required)  
     

Section 10 - What service(s) would you want to provide?

Number Question Effective Date Expiration Date
1. Companionship  
     
2. Personal Grooming and Dressing Assistance  
     
3. Toileting and Bathing Assistance  
     
4. Light Housekeeping  
     
5. Meal Preparation  
     
6. Transportation  
     
7. Shopping  
     
8. Yard Work  
     
9. Overnight Stays  
     
10. Pet Care  
     

Section 11 - Availability/Limitations

Number Question Effective Date Expiration Date
1. Available Monday?  
     
2. Available Tuesday?  
     
3. Available Wednesday?  
     
4. Available Thursday?  
     
5. Available Friday?  
     
6. Available Saturday?  
     
7. Available Sunday?  
     
8. Available as early as: ___ AM  
     
9. Available as late as: ___ PM  
     
10. Desired hourly wage:  
     
11. Desired weekly hours:  
  (Numeric Answer Only)    
12. Any concerns working around pets?  
     
13. Any concerns working in a smoking environment?  
     
14. Any physical restrictions or limitations?  
     

Section 12 - Emergency Contact Information

Number Question Effective Date Expiration Date
1. First Name: (required)  
     
2. Last Name: (required)  
     
3. Address:  
     
4. City:  
     
5. State:  
     
6. Zip Code:  
     
7. Phone 1: (required)  
     
8. Phone 2:  
     
9. Relationship: (required)  
     

Section 13 - Verification/Signature

Number Question Effective Date Expiration Date
1. Resident of PA for ___ years: (required)  
  (Numeric Answer Only)    
2. If PA resident less than 2 years, provide previous state of residence:  
     
3. "I certify that the facts contained in this application are true, accurate, and complete to the best of my knowledge; I understand that, if hired, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you." If you agree with this statement, please electronically sign your application by typing your full name. (required)  
     



I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.