Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Email
*
Phone Number
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about us?
*
Online
Friend/Family
Newspaper
Other
Do you have a current Driver's License?
Yes
No
Are you authorized to work in the United States on a full-time basis for all employers, or for your current employer only?
All Employers
Current Employer Only
Are you over the age of 18?
*
*Regulations require that applicants be 18 years of age or older
Yes
No
Have you ever been convicted of a felony?
*
* A conviction record will not necessarily bar you from being eligible for employment. This information will be used only for job related purposes and only to the extent permissible by law.
Yes
No
If YES, state nature of offense, when, where, and dispositon
Do you have Caregiving experience?
Yes
No
If YES, how many years? Please provide description of duties performed if not included on resume.
Do you have a CPR certification?
Yes
No
Hours Desired
*
Full Time
Part Time
Full Time Sub (Various Shifts)
Schedule Desired
8am-4pm
4pm-12am
12am-8am
Days you are able to work
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Date you are able to start work
*
MM
DD
YYYY
Are you willing to work overtime if requested?
Yes
No
Referred by:
*
i.e. friend/family/social media
State the name(s) or any relative(s) who are currently or have been in our employ and your relationship to them:
*
Is there any type of person that you feel you could not work with? Explain
*
(1) (a) RECORD OF EDUCATION
*
Please list name of school, address, and course of study (Starting with High School)
Did you graduate?
*
Yes
No
(b) Record of Education, cont.
Please list name of school, address, and course of study
Did you graduate?
Yes
No
(c) Record of Education, cont.
Please list name of school, address, and course of study
Did you graduate?
Yes
No
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Dates Worked
From
MM
DD
YYYY
to
MM
DD
YYYY
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Dates Worked
From
MM
DD
YYYY
to
MM
DD
YYYY
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Dates Worked
From
MM
DD
YYYY
to
MM
DD
YYYY
Phone
(###)
###
####
List any special skills that you believe are related to the job for which you are applying:
List any other experiences or abilities that you feel especially qualify you for work with our company:
Reference 1
First Name
Last Name
Reference Type
Professional
Personal
Employer
Friend
Occupation
Years Known
Phone
(###)
###
####
Reference 2
First Name
Last Name
Reference Type
Professional
Personal
Employer
Friend
Occupation
Phone
(###)
###
####
Years Known
Reference 3
First Name
Last Name
Reference Type
Professional
Personal
Employer
Friend
Occupation
Phone
(###)
###
####
Years Known
PRE-EMPLOYMENT STATEMENT (Please read carefully and check one of the box below)
I understand and agree that:
1. The information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification of refusal of employment, or, if employed, termination from TOUCH-STONE SOLUTIONS, INC.'s employ.
2. Any offer of employment I may receive from TOUCH-STONE SOLUTIONS, INC. is contingent upon my successful completion of the company's total pre-employment screening process, including the company's receiving references that it considers satisfactory, and my satisfactory completion of any post offer pre-employment medical examination (arranged by Touch-Stone Solutions, Inc.) that the company may require. I also agree, if employed, to submit to a medical examination at any time at the company's request. I hereby consent to having the results of any post-offer pre-employment or post-employment medical exams I may be required to take disclosed to TOUCH-STONE SOLUTIONS, INC.
3. I understand that as a condition of employment, I may be required to undergo and successfully pass a screening for drug usage. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of TOUCH-STONE SOLUTIONS, INC. I hereby consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to TOUCH-STONE SOLUTIONS, INC..
4. In processing my application for employment, the company may verify all the information provided by me or may procure or have prepared a consumer or an investigative consumer report for this purpose concerning my prior employment, military record, education, character, general reputation, personal characteristics, criminal record, and mode of living. I understand that upon written request to the company, I will be informed whether an investigative consumer report was requested and given full information as to the nature and scope of this investigation.
5. I authorize and request that all of my present and former employers and those individuals I have listed as personal references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information.
6. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the company and understand that my employment and compensation can be terminated with or without cause or notice, at any time, at the option of either the company or myself.
7. Touch-Stone Solutions, Inc. considers all applicants for employment without regard to race, color, religion, sex, national origin, age, handicap or disability, or status as a Vietnam-era or special disabled veteran in accordance with federal law. In addition, TOUCH-STONE SOLUTIONS, INC. complies with applicable state and local laws prohibiting discrimination in employment in every jurisdiction in which it maintains facilities. TOUCH-STONE SOLUTIONS, INC. also provides “reasonable accommodations” to qualified individuals with disabilities, in accordance with the Americans with Disabilities Act and applicable state and local laws.
8. Federal laws require that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with such laws, TOUCH-STONE SOLUTIONS, INC. will verify the status of every individual offered employment with the company. In this connection, all offers of employment are subject to verification of the applicant's identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization upon employment.
9. Due to the Nature of our Business, to be considered for hire, you are required to submit Act 34 (PA State Police: Request for Criminal Record Check), to sign PA Act 169 (Older Adults Protective Services Act) and, if you have lived outside the state of PA in the past two years, to submit Act 73 (FBI Fingerprint) clearances.
10. Touch-Stone Solutions, Inc. (Touch-Stone Solutions, Inc.) is an “At-Will” employer, which means that the term of employment is for no definite period of time and may be terminated by the employee or by Touch-Stone Solutions, Inc. at any time; and for any reason, with or without cause; and without prior notice. Any offer of employment is not to be considered a “contract”.
I agree to these employment terms
I DO NOT agree to these employment terms