Love Is Life Home Health Care LLC Job Application

Employment Application
Join Our Team at Love Is Life Home Health Care, LLC!
Philadelphia, USA
(267) 957-8096

Thank you for you interest in joining our team! Love Is Life Home Health Care LLC is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis of race, color, national origin, religious creed, ancestry, sex, age, or disability as prohibited by local, state, or federal law. Should an applicant need a reasonable accommodation in the application process, he or she should contact a company representative. Please fill in each section below. Incomplete/ illegible applications will not be accepted.

The following documents need to be turned in for every person seeking employment with Love Is Life Home Health Care, LLC: (these documents are needed to meet compliance with the Dept. of Heatlh and Federal Law for staffing)

1. Employment Application

2. Copy of High School Diploma or higher

3. Social Security Card

4. Driver's License or State- Issued ID

5. Form W-4 IRS tax form (Federal Income Taxes Employee Withholding form)

6. Criminal Background Check (through P.A.T.C.H)

7. Form I-9 (Employment Eligibility Verification form)

*In the state of PA, as a licensed Home Care Agency, we are mandated by the Department of Health to maintain a photocopy of your documents in our office for all employees and contractors, which will be kept safe and confidential and only disclosed when mandated by law or government regulations
Applicant Information
Applicant Name*

First NameMiddle NameLast Name
S.S. #*
Address*

Street Address

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
Please enter a valid email
In case of Emergency, who should we contact?*
Vehicle Information: (You will be required to have a valid driver's license and active auto insurance to run errands. Proof of insurance required and a motor vehicle check will be conducted)*
Employment Position
Position(s) applying for:*

Office ManagerStaffing ManagerCase ManagerHome Health Aide/ Personal Care Assistant (PCA)/ Direct Care Worker (DCW)/ CaregiverRespite Caregiver
How did you hear about this position?*
What days are you available for work?*
What hours or shift are you available for work? *
If needed, are you available to work overtime?*
On what date can you start working if you are hired?*

MonthDayYear
Enter date
Do you have reliable transportation to and from work?*

YesNo
Salary desired:*
Why are you interested in working with LIL HHC?*
Personal Information
Do you have any friends, relatives, or acquaintances working for Love Is Life Home Health Care LLC*

YesNo
If yes, state name & relationship:*
Have you ever applied for employment with this Agency?*

YesNo
Are you 18 years of age or older?*

YesNo
Are you a U.S. Citizen or approved to work in the United States?*

YesNoOther
Will you consent to a mandatory controlled substance test prior to and during employment?*

YesNo
What document can you provide as proof of Citizenship or legal status? Upload Identification and a Social Security Card*

Cancelof
Do you have any condition which would require job accommodations?*

YesNo
If yes, please describe accommodations required below.*
Do you consent to a mandatory Criminal Background Check ONLY AFTER a conditional offer of employment is made? (final hiring depends on the results of your background check and if a conviction is revealed, it is evaluated on a case-by-case basis). If you are rejected, (CB results can only be considered if they occurred less than 7 years from time of application; not including incarceration), Love Is Life Home Health Care will send a decision in writing with a copy of the background report that was used to determine our decision. You will have 10 days to provide evidence of the information's inaccuracy or rehabilitation.*

YesNo
Job Skills/ Qualifications
Are you currently employed?*

YesNo
Are you willing to provide service to a client with a pet? (Please specify)*

YesNocatdog
Are you willing to provide service to a client who smokes?*

YesNo
What areas are you willing to work*

Philadelphia Co.Bucks Co.Chester Co.Delaware Co.Montgomery Co.
Describe any training or life skills you possess that involve caring for adults.*
Please, also, include what you like the most and what you like the least about caring for adults.

These are services LIL HHC provides to its clients*

	Y	N
Personal Care
Light Housekeeping
Meal Preparation
Companion Care/ Activities
Alzheimer/ Dementia Care
Respite/ Relief Care
Laundry/ Ironing
Companionship

Which of the following are you willing to perform while caring for clients*

	Y	N
Medication Reminders
Post Surgery/ Maternity
Personal Assistance/ Errands
Lawn/ Garden Care
Hairstyling/ Grooming Care
Are you a licensed Hairstylist or Barber?

Previous Employer -*
Previous Employer -*
Previous Employer -*
Please, upload your Resume' for the position you are applying for.

(Note: Love Is Life Home Health Care complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/ employees to perform essential functions. It is possible that a hire may be tested on skill/ agility and may be subject to a medical examination conducted by a medical professional.
Cancelof
Education and Training
High School Name*
Location (City, State)*
Year Graduated*
Degree Earned*
College/ University Name*
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?*

YesNo
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?*
References (Do not include relatives)

Please provide 4 reference(s) below. We WILL contact these references. Please inform them in advance. Your application will not be considered if all 4 references are not provided and if we are unable to reach your reference; additional references will be required. You agree and consent to a reference check. The information obtained from previous employment will NOT be given to you.
Reference*
Provide name and relationship and years known
Contact Information*
Provide phone # and best time to call am/ pm
Reference*
Provide name and relationship and years known
Contact Information*
Provide phone # and best time to call am/ pm
Reference*
Provide name and relationship and years known
Contact Information*
Provide phone # and best time to call am/ pm
Reference*
Provide name and relationship and years known
Contact Information*
Provide phone # and best time to call am/ pm
AT-WILL EMPLOYMENT

The relationship between you and Love Is Life Home Health Care 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 Love Is Life Home Health Care. No representative of Love Is Life Home Health Care 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/ Chief Executive Officer .
Note to Applicant:

(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.) The use of illegal drugs is prohibited during employment. This application is not a contract of employment.
By signing, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, any falsified statements found in this application SHALL BE GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employers and others listed above form all liability for any damage that may resulft from furnishing the same to the Agency.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquuire as to whether or not applications are being accepted at that time.

Due to the nature of the busness, no amount of work can be guaranteed. By signing this application, I acknowledge that I have read, understand, and agree to the contents of this application.
Applicant Signature*

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Employment Application

Applicant Information

Employment Position

Personal Information

Job Skills/ Qualifications

Education and Training

Military:

References (Do not include relatives)

Note to Applicant: