Relevar Home Care

Application Form

Relevar Home Care is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, religion, age, sex, (including pregnancy and conditions related to pregnancy), national origin, disability, weight, height, misdemeanor arrest record, genetic information, sexual orientation, transgender status, marital or veteran status, or any other status protected under applicable law.

The following characters cannot be used on this form (%,&,/,?,>,<,|,{,})

Personal Information

First Name

M.I

Last Name

Home Phone

Cell Phone

Cell Phone Provider

Work Phone

How did you hear about us?

Address 1

Address 2

City

State/Prov

Postal Code

Position Applying For

SSN

(NNN-NN-NNNN)

Confirm SSN

How long at this address ?

Have you ever been convicted of a crime?

If yes, explain the nature and dates of the conviction(s)

What do you like most about working with the elderly, disabled, or convalescing client?

What do you find most challenging in this type of work?

Emergency Contact

Name

Alt Phone

Address

State

Phone

Relationship

City

Zip

Transportation

Do you have a car?

If you don’t have a car how would you get to work?

Driver’s License #

Expiration

Availability

How many hours can you work weekly?

Are you available to work nights?

Are you legally authorized to work in this country?

Would you consider live-in?

Employment Desired

Are you available to work weekends?

Available to Start Date

Are there any times you are not available to work?

Education

High School

Name

City

State/Prov

Level Completed

Degree

Major

College

Name

City

State/Prov

Degree

Major

Bus.or Trade School

Name

City

State/Prov

Degree

Major

Professional School

Name

City

State/Prov

Degree

Major

Certifications and Professional Licenses

	License number	Expiration date

Attributes

Please indicate whether you have assisted with or performed the following tasks

Companionship

Meal Preparation

Light Housekeeping

Bathing/Showering

Dressing/Grooming

Transferring

Incontinence Care

Dementia / Alzheimers

Additional Skills

Employment History (list most recent first)

Company

From

Job Title

Reason Left

Duties

Supervisor

Phone

May we contact?

Company

From

Job Title

Reason Left

Duties

Supervisor

Phone

May we contact?

Company

From

Job Title

Reason Left

Duties

Supervisor

Phone

May we contact?

References

Reference 1

Name

Relationship

Years Known

Phone

Reference 2

Name

Relationship

Years Known

Phone

Reference 3

Name

Relationship

Years Known

Phone

Reference 4

Name

Relationship

Years Known

Phone

Certification and Release Section

I certify and attest that the answers given on my resume and employment application and during all interviews are true and complete to the best of my knowledge and that I have not knowingly withheld any facts or circumstances. I also authorize investigation of all statements contained in this application, on my resume and during interviews as may be necessary in arriving at an employment decision. I agree that falsification or omission of any such information constitutes sufficient reason for denying me employment or for discharge from my employment.In consideration of my employment, I agree to conform to the rules, policies, procedures and regulations of RELEVAR, LLC as they now exist or as they are hereafter implemented or modified. I further agree that my employment and compensation can be terminated, with or without cause, at any time, by RELEVAR. I understand that no representative of RELEVAR, other than its President & CEO has anyauthority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, and any such agreement must be in a writing entitled “Employment Agreement” and executed by the President & CEO to be
enforceable.I agree that, to the extent permitted by law, any action or suit against RELEVAR (or any of its employees, officers, owners) which arises out of my employment or termination of employment, including, but not limited to, claims arising under state or federal civil rights statutes, must be brought within 180 days of the event giving rise to the claim or be forever barred. This applies to the initial filing of a charge with the Equal Employment Opportunity Commission; however thereafter I am permitted to pursue litigation, if at all, as explained in theCommission’s “Right to Sue” letter. I waive any longer, but not shorter, limitations periods to the contrary.I understand that, after receiving an offer of employment (and at any time thereafter), RELEVAR may require the successful completion of a drug test and/or a blood alcohol test as a condition of employment. By submitting this Application for Employment, I hereby consent to either or both tests, at RELEVAR's discretion, and agree that testing positive (regardless of any medical marijuana card) or refusing any such test whenever requested by RELEVAR constitutes sufficient reason for terminating my employment.I authorize RELEVAR (or its agent) to contact listed references, former employers, and any others who may have information concerning my application or qualification for employment. I also authorize a criminal background check both before and at any time during my employment. I release RELEVAR, its employees and those who supply RELEVAR with information that can be lawfully provided from any liability or damages which may result from furnishing the requested information including my failure to be hired for the position for which I am applying or any subsequent termination. I agree that RELEVAR shall have the right to refuse employment or terminate my employment based on any criminal record I may have that it deems relevant.I understand that if I am considered for a position requiring me to drive, I must have and maintain a valid driver’s license issued by my state of residence (without restrictions), a satisfactory driving record, current vehicle registration/plates, and automobile insurance with acceptable limits as a condition of my employment. I agree to allow RELEVAR (or its agent) to access my driving record prior to hiring me and, if hired, I give RELEVAR the right to check my record periodically thereafter. I further agree to report within 24 hours (to the
President/CEO) any driver’s license suspensions, restrictions, revocations, serious accidents or offenses, as well as any conditions that may affect my ability to drive safely after I am hired. I understand that RELEVAR will use this information for employment purposes only and not furnish this information to a third party without my written consent.I agree that any claim I may have under state or federal wage laws (including but not limited to the Fair Labor Standard Act, andMichigan’s Wages and Fringe Benefits Act, Minimum Wage Law and the Workforce Opportunity Wage Act), may only be pursued (1) through binding arbitration through the American Arbitration Association (AAA), held in Macomb County, and utilizing the AAA’semployment rules and (2) on an individual (not collective/class action) basis. I knowingly waive my right to pursue a civil action or participate in a collective/class action for any wage claim that I may have. Any award of the arbitrator shall be fully enforceable and a judgement may be entered in a court of competent jurisdiction. To the extent permitted by applicable law, the 180-day limitations period above shall apply to both my initial demand for arbitration at the AAA (which must be perfected within the 180-day period according toAAA’s rules, including payment of all filing fees required by AAA) and my initial notice to RELEVAR of the claim.I understand that, under Michigan law only, if as a result of a disability I require a reasonable accommodation in order to perform the essential functions of my position, I must ask for that, in writing, within 182 days of the day I knew or should have known of that need.I agree to all of the above terms:

Date

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