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Online Application for Employment

NOTE: This form is intended for use in evaluating your qualifications for employment. Please answer all questions completely and accurately. False or misleading statements on this form and during the interview are grounds for terminating the application process or, if discovered after employment commences, terminating employment. Independence Home Care, Inc. is an equal opportunity employer and does not discriminate on the basis of gender, race, age, creed, marital status, pregnancy, sexual orientation, national origin, religion, veteran status, presence of disabilities, and on any other status protected by law. Upon hiring, you must provide a current statement of good health from your physician including a recent negative tuberculosis (TB) test.
Application Date*
Personal Information
Name*
FirstLast
Home Phone*
Cell Phone*
Alt. Phone
Social Security #*
Email*
Enter EmailConfirm Email
Current Address*
Street AddressCityStateZip Code
Previous Address*
Street AddressCityStateZip Code
How did you hear about IHC?*
Why are you interested in employment with IHC?*
Do you have a valid driver’s license?*
- Yes
- No
From what State?*
License number*
Make & Year of Vehicle
Auto Insurance Co.
Policy Number
Have you had any moving violations in the last 3 years?*
- Yes
- No
Please Describe:
Work Preferences*
- Full Time
- Part Time
- Per Diem
Approximately how many hours per week do you wish to work? *
Are you willing to work weekends or on call as needed? *
Education, Certifications & Work Experience
High School*
City, State or Country*
Graduate*
- Yes
- No
Number of Years Completed*
College*
City, State or Country*
Graduate*
- Yes
- No
Number of Years Completed*
Professional License or Certification 1 (if applicable):
Number
State
Currently Active?
- Yes
- No
Expiration Date
Has your license or certification ever been suspended or revoked?
- Yes
- No
Please Explain*
List the type of incident, city/state and charge.
Professional License or Certification 2 (if applicable):
Number
State
Currently Active?
- Yes
- No
Expiration Date
Has your license or certification ever been suspended or revoked?
- Yes
- No
Please Explain*
List the type of incident, city/state and charge.
Professional Experience - Check all that apply:
- Acute Care
- Long Term Care
- Home Health
- Skilled Nursing
- Hospice
- Hospital
- Rehabilitation
- Personal Care
- Companion
Have you ever been discharged from a job or forced to resign?*
- Yes
- No
Please Explain:*
Please list your most recent employment*
From: To: Job Title: Name of Employer: Phone: Address of Employer: Reason for Leaving: Job Duties:
Please list your second most recent employment*
From: To: Job Title: Name of Employer: Phone: Address of Employer: Reason for Leaving: Job Duties:
Please list your third most recent employment*
From: To: Job Title: Name of Employer: Phone: Address of Employer: Reason for Leaving: Job Duties:
Personal References
Reference #1
Name: Address: Telephone: Relationship:
*no family or relatives
Reference #2
Name: Address: Telephone: Relationship:
* no family or relatives
Please list states and counties of residence for the past seven years: *
Have you used any names or Social Security numbers other than those on this application?*
- Yes
- No
Please list names or Social Security numbers you've used:
Upload your Cover Letter (optional)
Upload your Resume (optional)
Agreement & Authorization
I hereby authorize Independence Home Care, Inc. to request and receive from all prior employers within one year of the date of this application, any and all pertinent information to my prior employment and its termination, including the reasons for such terminations. 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, and all schooling and references. I agree to indemnify and hold harmless Independence Home Care, Inc. and any of its agents or employees from all liability which may flow from the release of such information.

I understand that if I am hired my employment will be on an at-will basis, for no definite term. As such, I understand that I will enjoy the right to terminate my employment at anytime subject to providing two weeks written notice. Independence Home Care, Inc. may also terminate my employment at any time with or without cause. I further acknowledge that if offered employment I will be expected to learn and abide by all Company rules, policies, and procedures. I also understand that the use of illegal drugs is strictly prohibited while employed by Independence Home Care, Inc. and I am willing to submit to random drug testing to detect the use of illegal drugs prior to and during employment. Nothing contained in this employment application or in the granting of an interview is intended or designed to constitute an offer of employment or an employment contract between myself and Independence Home Care, Inc. I hereby state that all of the foregoing information I have supplied in this application is a true and a complete statement of the facts. I understand that false statements contained in this application are immediate cause for dismissal.
I have read the Terms of this Agreement*
- I agree & authorize

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Online Application for Employment

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Agreement & Authorization