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Emergency Contact Information

Are you at least 18 years of age?


Not necessary to indicate the need for absences due to religious practices or obligations.

Health Professionals Only:

Health Professionals Only:

Education

Name, City, State Degree/Certificate Did You Graduate?
High School
Nursing/Tech School
College
Post-College
Other Training

Professional Affiliations/Organizations

Note: Please exclude activities that indicate any legally protected characteristics or practices.

Name/Type Member Number Exp. Date

Past Employment or Job Related Volunteer Experience

Note: Do not list any volunteer experience if a volunteer must be a particular race, national origin, religion or other protected basis.

Past Employment or Volunteer Experience











Dates of Employment



Past Employer or Volunteer Experience











Dates of Employment



Past Employer or Volunteer Experience











Dates of Employment



Licensure (Health Professionals Only)

Type State License/Cert. Number Exp. Date Active

Certifications (Health Professionals Only)

Type Expiration
Other Certifications Expiration

Additional Work Related References

Note: Please list references other than relatives.

Reference

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Reference

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Right at Home provides in-home care services to clients and equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, disability, or other protected class, in compliance with all applicable federal, state and local laws. Each Right at Home office and business is independently owned and operated under a franchise agreement with Right at Home, Inc. For comments, questions or to learn more about Right at Home, please visit www.rightathome.net

Please Read Carefully

I certify that the information contained in this application is true, accurate, complete and correct. I understand and agree that any misrepresentation, falsification, or material omission of information on this application or any resume I submit may be grounds for the Company to refuse to employ me or terminate my at-will employment if I am hired. I further understand that the decision to hire is solely that of the Company.

I understand and acknowledge that I am applying for a position with the Right at Home franchise identified on this web page (hereinafter the “Company”), which Company is independently owned and operated pursuant to a franchise agreement with Right at Home Inc., and that I am not applying for a position with the Company and not Right at Home, Inc. and if I am hired by the Company I will not be an employee of the Company and not Right at Home, Inc.

I acknowledge that due to the nature of the Company’s business, attendance and punctuality are essential requirements of every job and that poor attendance or tardiness will result in disciplinary action or termination.

I authorize the investigation of all the information I provided in this application, unless I have indicated otherwise. To the maximum extent allowed by law, I authorize any insurance company, employer, educational institution, law enforcement organization, governmental agency, information service bureau, medical facility or practitioner, and/or any other person or entity listed in this application to release information regarding me and my character, including but not limited to my performance, qualifications, disciplinary information, background, reasons for termination of past employment or volunteer service, and eligibility for rehire, to the Company and its affiliated entities, parent companies, franchisors, other franchisees, representatives, employees and clients. Also, to the maximum extent allowed by law, I waive written notice to me that employment information is provided by any person or entity.

I also understand that as a condition of my application and at-will employment I will complete a background check including, but not limited to, criminal record check, social security number verification, and driving record, as allowed by law. I also authorize the release of my background check information, social security number verification, driving history and criminal records, and understand that they may contain information about my background, mode of living, character, and personal reputation, as allowed by law.

I authorize the disclosure of all information about me, including but not limited to information obtained from the parties, entities and references I listed in this document, as well as information obtained by, through or from any background, employment, social security verification, driving record, and or criminal history checks, to the Company and its affiliated entities, parent companies, franchisors, other franchisees, representatives, employees and clients.

I release the Company and its owners, agents, employees, officers, directors, attorneys, representatives, clients, insurers, parent companies, franchisors, other franchisees, and affiliated entities and persons from any and all liability as a result of soliciting, providing or receiving information regarding me or my character, or the use or disclosure of such information.

The Company does not unlawfully discriminate in referrals, placements, or employment, and no question on this application is used for the purpose of limiting or excluding any applicant for consideration for referral, placement or employment on any basis prohibited by applicable laws or regulations.

I understand and agree that the information supplied on this application has been given for the purpose of evaluating my qualifications for employment with the Company. However, I understand and agree that the Company does not guarantee my referral, placement, employment or terms of employment.

I acknowledge that any offer of employment to me by the Company is contingent upon my timely completing INS Form I-9 and producing the proper documents required by the Immigration Reform and Control Act of 1986. My failure to meet these requirements within the specified time will result in the termination of employment.

I acknowledge that I have been advised that this application will remain active for no more than sixty (60) days from the date it was made.

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(512) 531-9453

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