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PRELIMINARY EMPLOYMENT APPLICATION

We are a job placement / referal agency. A-1 Domestic is always looking to hire experienced Caregivers, Companions, Aides, Assistants, CNA, CHHA, Home Attendants, Sitters, Au Pair, Babysitters, Homemakers, Mother's Helper & Nannies for non-medical In Home Care and Child Care services.

We are an equal opportunity employer. Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and / or interview process should notify a our Human Resources Department.

Contact Information:
Name
Nick Name
Address
E-Mail
Home Phone
Cell
Work
May we contact you at work? Yes No
If yes, best time to reach you at work:
Genearl Information:
If under 18, can you furnish a work permit? Yes No
If no, please explain:
Have you submitted an application previously? Yes No
If yes, give date(s):
Have you ever been employed here before? Yes No
If yes, give date(s):
Are you legally eligible to work in this country? Yes No
Date available to work:
Position desired: Full-Time Part-Time Temporary
  Seasonal Educational Co-op
Will you relocate if job requires it? Yes No
Will you travel if job requires it? Yes No
Driver's license number: State:
Are you able to meet the attendance requirements of the position? Yes No
Will you work overtime if required? Yes No
If no, please explain:
Have you ever been bonded? Yes No
Have you been convicted of a crime in the last 7 years? Yes No
If yes, please explain:
Conviction will not necessarily be a bar to employment. Each instance and explaination will be considered in relation to the position for which you are applying.
Employment History:
Most Recent Employer
Employer
Telephone
Address
Supervisor and Title
May we call for reference? Yes No
Your Job Title
Summarize the type of work performed and job responsibilities

Dates Employed

Starting Rate / Salary

Final Rate / Salary
From To $ per $ per

Comments
(including explanation of
any gaps in employment)

Other Employment
Employer
Telephone
Address
Supervisor and Title
May we call for reference? Yes No
Your Job Title
Summarize the type of work performed and job responsibilities

Dates Employed

Starting Rate / Salary

Final Rate / Salary
From To $ per $ per
Comments (including explanation of any gaps in employment)
   
Skills and Qualifications:
Summarize any special training,skills, licenses and / or certificates that may qualify you as being able to perform job- related finctions in the position for which you are applying.
Educational Background:

List the last three (3) schools attended, starting with most recent. List number of years completed. Indicate degree or diploma earned, if any. List grade point average and class rank. As well as major and minor (if applicable) field of study.

School

Years Completed

Degree / Diploma

GPA / Class Rank

Major

Minor

Reference:

List name and telephone number of three (3) business / work references who are not related to you and are not previous supervisors. If not applicable, list three (3) school or personal references who are not related to you.

Name of Reference

Telephone Number

Years Known

Additional Information:

List professional, trade, business, or civic associations and any offices held. Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status.

Organization

Offices Held

List special awards,
accomplishments,
publications, etc.

List any additional
information you would
like us to consider.

Reffral Method:
Relative
Employee
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Note: Policy requires all applicants also fill out an application in person at our corporate headquarters. The information above is an exact copy of what will be asked on our paper application. If you'd like, please print this page for easy reference when called for an interview.




To hire a companion caregiver, call A-1 Domestic Professional Services or A-1 Home Care or LA In-Home Care Services at 877-929-8499