Application | Marcan Home Care

Applicant Information

First and Last Name

Address

Phone

Email

Date of Application

Month

Day

Year

Employment Position

How did you hear about this position?

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

What hours or shift are you available for work?

8 AM – 4 PM

4 PM – 12 AM

12 AM – 8 AM

Do you have reliable transportation to and from work?

Yes

No

Personal Information

Are you 18 years of age or older?

Yes

No

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

Yes

No

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

Will you consent to a mandatory controlled substance test?

Yes

No

Do you have any condition which would require job accommodations?

Yes

No

If yes, please describe accommodations required below.

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

Yes

No

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

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the

nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and

the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

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

(Note: Marcan Homecare LLC 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

Previous Employment

Employer Name 1

Job Title

Supervisor Name

Employer Address (City, State and Zip Code)

Employer Telephone

Dates Employed - Start Date

Dates Employed - End Date

Reason for leaving

Employer Name 2

Job Title

Supervisor Name

Employer Address (City, State and Zip Code)

Employer Telephone

Dates Employed - Start Date

Dates Employed - End Date

Reason for leaving

References

Please provide 2 personal and professional reference(s) below:

Reference - Contact Information

AT-WILL EMPLOYMENT

The relationship between you and the Marcan Homecare LLC 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 Marcan

Homecare LLC. No representative of Marcan Homecare LLC 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.

Signature

Signature field is empty.

Date

Month

Day

Year

Job Application

Applicant Information

Employment Position

Personal Information

Job Skills/Qualifications

Education and Training

Previous Employment

References