Automatic Home Care — Client Management

Position Information

Position Applied For

Date Available to Start

Employment Type Desired

Desired Pay Rate (optional)

Personal Information

First Name *

Last Name *

Street Address

City

State

ZIP

Phone *

Email

Date of Birth

Are you legally eligible to work in the United States?

Have you ever been convicted of a felony or misdemeanor?

Availability

Education & Certifications

High School Attended

Graduated / GED?

College / University Attended

Degree (if applicable)

Graduated?

Certifications / Training (CNA, CPR/First Aid, Peer Support, etc.)

Employment History

References

Certification & Signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false statements or omissions may disqualify me from employment or result in termination if discovered after hire. I authorize Automatic Home Care, LLC to verify the information provided, including contacting references and previous employers, and to conduct a background check as permitted by law.

Type Your Full Legal Name *

Draw Your Signature *

Sign here

I have read and agree to the certification statement above.

AUTOMATIC HOME CARE, LLC