Application for Employment

Golden Horizons ElderCare Services, Inc.

251 Main St. #201
Old Saybrook, CT 06475

Contact: (860) 388-1788

Please fill out completely. All qualified applicants will be considered without discrimination due to race, color, religion, sexual orientation, gender, disability, veteran status or national origin.











Languages:



List Hours and Days Available to Work

What is your availability? Check all that apply.









What times of the day are you available? Check all that apply.




If you have specific scheduling needs - days, times etc. - please list them here.

Date you can start:


General Questions

INSTRUCTIONS: Please complete all sections of this application to the best of your ability. If you have questions during any phase the employment process, please call 860-388-1788. All qualified applicants will receive consideration without discrimination due to race, color, religion, gender, sexual orientation, disability, veteran status or national origin.
Do you have a legal right to hold employment in the USA full time?

Are you at least 18 years old?

Social Security Number

If you do not have a social security number, enter "N/A".
Which position are you applying for? Check all that apply.




Minimum Wage Desired Per Hour:

Minimum Wage Desired for a 24 Hour Live-in:

Have you ever worked for our company? If yes, when?

Please include dates.
Are you related to anyone employed by our company?

If yes, please list the person's name and position.


High School Education

Name and location of high school:

Enter in the city and state. If you did not attend high school, enter "N/A".
Did you graduate?

Year of graduation:

If you did not attend high school, enter "N/A".


College Education (Optional)

Name and location of college or university:

Include city and state (or country). If you did not attend college or university, enter "N/A".
Did you graduate?

Year of graduation:

If you did not attend college or university, enter "N/A".
If you did not graduate, how many years did you attend?

If you did not attend college or university, enter "N/A".
Major course of study:

If you had more than one major, please list all. If you did not attend college or university, enter "N/A".


Technical, Trade, Grad School, Other (Optional)

Did you attend a trade school or technical school?

If YES, name and location of school and course of study.

Include city and state (or country). If your did not attend trade school or technical school, enter "N/A".
Did you graduate?

If YES, what year?

If you did not attend trade school or technical school, enter "N/A".
Did you attend graduate school?

If YES, what year?

If you did not attend graduate school, enter "N/A".
Did you graduate?

If YES, name and location of school and course of study.

Include city and state (or country). If did not attend graduate school, enter "N/A".


Certifications & Special Training

What are your certifications? Check all that apply.







For all certifications you checked off, please list the state in which you received your certification, the year you received it, when it expires and the school/location where you received it.

If you have no certifications, please enter N/A.
Do you have special training or experience in any of the following? Check all that apply.








For any special training or experience you checked off above, please indicate whether it is on-the-job training/experience or a class/clinical. If you received training in class/clinical, please indicate the school/location.

If you have not received special training or experience, enter "N/A".


Transportation

Do you have a driver's license?

Do you own a car?

If YES, make and year:

If you do not own a car, enter "N/A"
If you do not have a driver's license, or a vehicle, do you have a reliable means of transportation?

If YES, what is your reliable means of transportation?

If you do not have a reliable means of transportation, enter "N/A".


Most Recent Employment History

May we contact your business references?

These are your supervisors from your previous employment.
Company Name:

Your most recent position.
Company Address:

Please enter legal address (physical location) - street, city/town, state and zip code.
Company Phone:

Dates of Employment - Starting and Ending:

Example: Jan 1, 1014 - June 1, 2014
Position and Responsibilities:

Please state the job title and duties performed.
Supervisor's Name & Title:

Supervisor's Contact Information:

Please enter in a phone number and email address.
Reason for Leaving:



Past Employment History

1: Company Name:

Note: Please list additional employment (after most recent listed above) in reverse chronological order from next most recent.
Company Address & Phone:

Please list street, city/town, state, zip code (and country if applicable).
Dates of Employment - Starting and Ending Dates:

Example: Jan 1, 1014 - June 1, 2014
Position and Responsibilities:

Please state the job title and duties performed.
Supervisor's Name, Title & Contact Info:

Please include a phone number and email address.
Reason for Leaving:

2: Company Name:

Company Address & Phone:

Please list street, city/town, state, zip code (and country if applicable).
Dates of Employment - Starting and Ending Dates

Example: Jan 1, 1014 - June 1, 2014
Position and Responsibilities:

Please state the job title and duties performed.
Supervisor's Name, Title & Contact Info:

Please include a phone number and email address.
Reason for Leaving:

3: Company Name:

Company Address & Phone:

Please list street, city/town, state, zip code (and country if applicable).
Dates of Employment - Starting and Ending Dates:

Example: Jan 1, 1014 - June 1, 2014
Positions and Responsibilities:

Please state the job title and duties performed.
Supervisor's Name, Title & Contact Info:

Please include a phone number and email address.
Reason for Leaving:

Please list any additional past employment here.

Include Company Name, Address, Phone, Supervisor's Name & Title, Dates of Employment, Reason for Leaving. If you do not have additional employment history, enter "N/A".


Emergency Contacts

Emergency Contact 1

Include name, relationship to you, and phone number (home, cell, work).
Emergency Contact 2

Include name, relationship to you, and phone number (home, cell, work).
Emergency Contact 3

Include name, relationship to you, and phone number (home, cell, work).


Notice to Applicants

I agree, in consideration of your employing me, that I will not seek or accept employment either directly or indirectly, in this state or any other, from any client of Golden Horizons Elder Care Services, Inc., for at least three months after the official date of employment termination.
It is understood that this restriction shall terminate three months after receiving or giving written notice of employment termination. If for any reason I violate the terms of this agreement, I agree to pay Golden Horizons Elder Care Services, Inc., liquidated damages equaling 3 month’s equivalent of client’s fees.
I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.
Per Connecticut General Statutes Section 31-51i, you, the applicant, are not required to disclose the existence of any arrest, criminal charge or conviction, or criminal records subject to erasure pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon.
I hereby swear that all of the information in my personnel file has been voluntarily given to Golden Horizons Elder Care Services, Inc. I also hereby give Golden Horizons permission to check my references provided and to conduct a criminal background check.
Indicate permission here (yes/no).


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