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.
Please Enter First Name
Please Enter LastName
Please Enter Home Phone Number
Please Enter Cell Phone Number
Please Enter E-mail Address
Please Enter Address1
Please Enter City
Please Enter State/Prov
Please Enter Postal Code
Please Enter the Position Applying For
Please Enter SSN
Please Enter How long at this address
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Personal Information
First Name
*
M.I
Last Name
*
Home Phone
*
Cell Phone
*
Cell Phone Provider
Please Select
Alaska Communications
Alltell
ATT
Bell Mobility
Bluegrass Cellular
Boost
C Spire
Cincinnati Bell
Cingular
Cricket
Fido
Freedom Mobile
GCI Wireless
Helio
Koodo Mobile
MetroPCS
My Family Mobile
Nextel
Qwest
Rogers
Rogers Wireless
Simple Mobile 1
Simple Mobile 2
Solo
SouthernLINC
Sprint
Straight Talk
T-Mobile
Telus
US Cellular
Verizon
Virgin
Virgin Canada
Wind
Xfinity
Work Phone
Email
*
How did you hear about us?
Care.com
Client Referral
Dorsey School
Employee Referral
Facebook
Google/Internet Search
Handshake
Holly Blanco
Indeed
jennifer wilson
Job Fair
jsloan@relevar.com
Michigan Works
Oakland Community College
recruiter@relevar.com
Rehire Email/Cold Call
Relevar Sign
Relevar Website
Word of Mouth
Other
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?
No
Yes
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?
No
Yes
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?
Yes
No
SomeTimes
Are you legally authorized to work in this country?
Yes
No
Would you consider live-in?
Yes
No
Employment Desired
Full Time
Part Time
Full or Part Time
Are you available to work weekends?
Yes
No
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
Yes
No
Meal Preparation
Yes
No
Light Housekeeping
Yes
No
Bathing/Showering
Yes
No
Dressing/Grooming
Yes
No
Transferring
Yes
No
Incontinence Care
Yes
No
Dementia / Alzheimers
Yes
No
Additional Skills
Employment History (list most recent first)
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact?
Yes
No
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact?
Yes
No
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact?
Yes
No
Professional References (manager, supervisor, etc.)
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 CEO has any authority 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 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, directors or representatives), 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 the Commission’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:
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