Job Application

At Your Service HomeCare INC
1661 Worcester Rd. Suite 303, Framingham, MA, 01701
508-877-1326

At Your Service HomeCare INC is an equal opportunity employer. This application will not be used for limiting or excluding
any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant
need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:

Applicant Information

Applicant Name:

Date of Application:

Address:

City, State and Zip Code:

Telephone Number:

Email Address:

Employment Position:

Position(s) applying for:

How did you hear about this position?

What days are you available to work?

What hours or shifts are available for you to work?

On what date can you start working if you are hired?

Do you have reliable transportation to and from work?

Personal Information

Do you have any friend, relatives, or acquaintances working for At Your Service Home Care INC

Yes

If yes, state name & relationship:

Are you 18 years of age or older?

Yes

Are you a U.S citizen or approved to work in the United States?

Yes

What document can you provide as proof of citizenship or legal status?

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: At Your Service HomeCare INC complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. )

Education and Training

High School

Location (City, State)

Year Graduated

Degree Earned

College/University

Location (City, State)

Year Graduated

Degree Earned

Vocational School/Specialized Training

Location (City, State)

Year Graduated

Degree Earned

Military

Are you a member of the Armed Services?

What branch of the military did you enlist?

What was your military rank when discharged?

How many years did you serve in the military?

What military skills do you possess that would be an asset for this position?

Previous Employment

Employer Name 1:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

Employer Name 2:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

Employer Name 3:

Job Title:

Supervisor Name:

Employer Address:

City, State and Zip Code:

Employer Telephone:

Dates Employed:

Reason for leaving:

References

Please provide 3 personal and professional reference(s) below:

Reference

Contact Information

AT-WILL EMPLOYMENT

The relationship between you and the At Your Service HomeCare INC is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the At Your Service HomeCare INC. No representative of At Your Service HomeCare INC has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice President/Chief Operations Officer or the Company's President.

Applicant Signature:

Dated:

Name

This field is for validation purposes and should be left unchanged.

Job Application

At Your Service HomeCare INC 1661 Worcester Rd. Suite 303, Framingham, MA, 01701 508-877-1326

Applicant Information

Employment Position:

Personal Information

Job Skills/Qualifications

Education and Training

Military

Previous Employment

References

AT-WILL EMPLOYMENT

Schedule An Appointment today!

At Your Service HomeCare INC
1661 Worcester Rd. Suite 303, Framingham, MA, 01701
508-877-1326