Employment application

Serene Home Care Services LLC is an equal opportunity employer. We do not discriminate based on race, creed, color, religion, sex, age, national origin, ancestry, disability, veteran status, or any other protected classification under federal or state law.

Fields marked * are required.

Applicant information

Today’s date *First name *Middle nameLast name *Home addressCityStateZIP codeMobile phone *Email address *CertificationAre you a U.S. citizen or legal resident?Country of birthCity of birthAuthorized to work in the United States without restrictions?Anticipated start date

Availability

Select all that apply Full-time with weekends Part-time PRN Weekdays only Weekends only Live-in full-time Live-in part-time

Background disclosure

Besides a minor traffic violation, is there anything in your background that would prevent you from working in a home care environment?If yes, please explain

Education

High schoolHigh school locationQualificationCollege or universityCollege or university locationCurrently enrolled?Degree earned or program

Employer 1

Please list a minimum of five years of healthcare or direct-care experience. By completing this section, you authorize Serene Home Care Services LLC to contact previous employers to verify employment and references.

Company name *CityZIP codeJob titleStart dateEnd dateReason for leavingSupervisor nameSupervisor phoneSummary of duties

Employer 2

Company nameCityZIP codeJob titleStart dateEnd dateReason for leavingSupervisor nameSupervisor phoneSummary of duties

Emergency contact 1

NameRelationshipPhoneEmail

Emergency contact 2

NameRelationshipPhoneEmail

Applicant certification and authorization

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may result in disqualification from employment or termination if discovered after hire. I authorize Serene Home Care Services LLC to verify all information listed in this application, including education, certification, employment history, and references. I acknowledge that failure to verify required credentials or background eligibility may result in withdrawal of employment consideration or dismissal.

I agree to the certification and authorization above *Applicant signature (type your full name) *Signature date *