APPLICATION FOR EMPLOYMENTPlease print or type all information except signature.
NOTE: This form is intended for use in evaluating your qualifications for employment. Please answer all questions
completely and accurately. False or misleading statements on this form and during the interview are grounds for
terminating the application process or, if discovered after employment commences, terminating employment. UCSL
Home Care is an equal opportunity employer and does not discriminate based on gender, race, age, creed, marital
status, pregnancy, sexual orientation, national origin, religion, veteran status, presence of disabilities, and on any other status protected by law. Upon hiring, you must provide a current statement of good health from your physician including a recent negative tuberculosis (TB) test.
- Note: Upon interview, please provide a copy of your driver’s license and auto insurance policy.
Ultimate Care Supported Living, LLC | 5310 E Main St, Columbus OH 43213, U. S. A
Tel: +1 614.868-3821. Fax: + 614-868-3921 E-mail: firstname.lastname@example.org
- EDUCATION, LICENSES, & CERTIFICATIONS
License or Certification 1 (if applicable):
License or Certification 2 (if applicable):
- PERSONAL REFERENCES
(As a condition of employment all employees must be “bondable.”)
- WORK EXPERIENCE
(Please list present and past employment beginning with your most recent.)
- CERTIFICATION, AGREEMENT, & RELEASE
hereby authorize Ultimate Care Supported Living, LLC to
request and receive from all prior employers within one year of the date of this application, any and
all pertinent information to my prior employment and its termination, including the reasons for such
terminations. I authorize the company and/or its agents, including consumer reporting bureaus, to
verify any of this information including, but not limited to, criminal history and motor vehicle driving
records, and all schooling and references. I agree to indemnify and hold harmless UCSL and any of its
agents or employees from all liability, which may flow from the release of such information.
I understand that if I am hired my employment will be on an at-will, per-diem basis, for no definite
term. Hours cannot be guaranteed and are subject to change. As such, I understand that I will
enjoy the right to terminate my employment at any time. Ultimate Care Supported Living, LLC may
also terminate my employment at any time with or without cause and/or prior notice. I further
acknowledge that if offered employment I will be expected to learn and abide by all Company
rules, policies, and procedures I also understand that the use of illegal drugs is strictly prohibited
while employed by Ultimate Care Supported Living, LLC and I am willing to submit to random drug
testing to detect the use of illegal drugs prior to and during employment. Nothing contained in this
employment application or in the granting of an interview is intended or designed to constitute an
offer of employment or an employment contract between Ultimate Care Supported Living, LLC and
I hereby state that all of the foregoing information I have supplied in this application is a true and a
complete statement of the facts. I understand that false statements contained in this application are
immediate cause for dismissal.
- FOR OFFICE USE ONLY
- Reference / Employment Check