In case of an emergency, we will contact the individual below

List the work, military or volunteering experience below. Specify the 3 most resent entries.

List the educational experience below.  Start with the highest or the most relevant to the position .

Starting by entering the most relevant licensure or certification.  Do not list expired ones.

Provide at least 3 professional or school reference. DO NOT include family members.

Indicate the employment preferences, conditions, and interest.

You can attach up to 5 additional documents to your application for further consideration.  for example, resume, cover letter, copy of diploma/license/certificate, letter of recommendation etc.

By signing below

I declare that all information provided on my application to be a candidate for Golden Years Care Agency of any information provided as attachments to my application are true, accurate, and can be verified if necessary.  I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment or if discovered after employment begins, could result in termination of employment.

By signing below, I certify that affirm that to the best of my knowledge and belief, I have not or have not had a case of abuse, neglect, mistreatment, or exploitation substantiated against me.

As a condition of submitting my application and in order to verify that affirmation, I hereby authorize Golden Years Home care Agency to have full and complete access to any and all current or prior personnel or investigative records, form any party, person, business, enity or agency, whether governmental, or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment or  exploitation and to be consider this information as may be deemed appropriate.

I further authorize Golden Years Home Care Agency to provide any applicable information in personnel or investigate records concerning my employment to my future employers involved in providing services.

I hereby authorize Golden Years Home Care Agency to verify information provided on the employment application.  Information subject to verification  includes but is not limited to:

Former employment: dates of employment, main responsibilities, average of hours per week, supervising experience, quality of work performed, key strengths and areas for improvement, communication skills, reason form leaving organization and eligibility for rehire.

Education, Licensure and Certification: Existence on registry, degree, GPA, expiration date.

Instructions: Please read carefully before completing this form.

Golden Years Home Care Agency is committed to the principle of equal employment opportunity.  any employment decision or treatment is based on valid job requirements without any regard to race/ethnicity, color, religion, sex(including pregnancy), national origin, age, disability, veterans.  Employment process includes training & mentoring programs and other outreach efforts to explain work process in great details. Reasonable accommodations are provide to known physical or mental limitation which are not preventing applicant or employee from performing essential job functions.

Golden Years Home Care Agency is subject to certain non-discrimination record keeping and reporting requirements which require the employer to invite employees to voluntarily self-identify their race/ethnicity.

Submission of this information in voluntary and refused to provide it will not subject you to any adverse treatment.

The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including more which requires the information to be summarized and reported to the federal government for civil right enforcement purpose.

If you chose not to self-identify your race/ethnicity at this time, the federal government requires this employer to determine this information by visual survey and/or other available information.

For civil rights monitoring and enforcement purposes only, all race/ethnicity information will be collected and reported  in the seven categories identified below.  The definitions for each category have been established by the federal government.  If you choose to voluntarily self- identify, you may mark only one of the boxes presented below.

I hereby authorize Global Years Home Care Agency to request a criminal history records check, and I further authorize the State Police to release information relative to the existence of any criminal record which it may have concerning me to the requestor solely to determine my suitability for employment or continued employment.

I future authorize any agency which maintains records relating to me to provide the same on the request.  I certify that the State Police and any agency who furnish this information shall be held harmless from any and all liability which may be incurred as a result of releasing such information.  I further acknowledge that Golden Years Home Care Agency shall not be liable for the failure to hire or to retain an applicant or employee who has been convicted of committing or attempting to commit crime which has been expunged.

I understand that the information requested below regarding date of birth, gender, race/ethnicity is for the sole purpose of identification and the gathering of the above-mentioned information about me accurately, and that it will not be used to discriminate against me in violation of the law, I understand that the provision of my social security number is required by law.  A facsimile or photographic copy of this authorization will be as valid as the original.

Previous address (if changed within 5 years)

I declare that all information provided on this document is true and accurate.

I understand that any false statements or deliberate omissions on this documents may be grounds for disqualification from employment or if discovered  after employment begins, could result in termination of employment.

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