Employment Application – Allied Care

CHHA Job Application Information

All CHHAs must read before filling out the Employment Application

Required Documents:

Copy of U.S. Passport or Permanent Green Card
Copy of Driver’s License or State ID
Copy of Social Security Card
Copy of CHHA License
One Photo (Passport Size)

Other Required Forms (Download):

Employee Physical Examination Record (to be completed by a Doctor)
IRS Form W-4
IRS Form 8850
Work Opportunity Tax Credit Form (if applicable)

Personal Information
Your name*
First Last
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY
Current Address*
Street Address City State / Province / Region ZIP / Postal Code
Is this your Permanent Mailing address?*
- Yes
- No
Mailing Address
Street Address City State / Province / Region ZIP / Postal Code
Referred by
Emergency Contact Information
Emergency Contact
Please list up to three (3) people
Name Relationship Phone/Cell No.
Employment Desired
Position*
Date You Can Begin Work*
MM slash DD slash YYYY
Salary Desired
Are you currently employed?*
- Yes
- No
If so, may we contact your present employer?
- Yes
- No
Are you legally authorized to work in the U.S.?*
- Yes
- No
Have you ever applied to this company?*
- Yes
- No
Where?
When?
Education History
High School
School Name City Years Attended
Did you graduate from high school?*
- Yes
- No
College
School Name City Years Attended Subjects Studied
Did you graduate from college?*
- Yes
- No
Training & Certification
School Name City Completion Date
Trade, Business, or Correspondence School
School Name City Years Attended Did you graduate? Subjects Studied
License & Insurance Information
License
CHHA/RN License Number Date of Issue Expiration Date Issuing Authority
Malpractice Insurance
Policy Number Date of Issue Expiration Date Insured by
Former Employers
List your last three employers, starting with the most recent
List your last three employers, starting with the most recent
Start Date End Date Employer Name Address Salary Position Reason for leaving
General Information
Languages Spoken
Check all that apply
- English
- Español
- Hindi
- Gujarati
- Other (Specify)
Other Language(s)
Special Training
Special Skills
Authorization
I certify that the information given in this application is true and accurate. I authorize Allied Care Corporation to request and receive from all previous employers within a one year period from the date of application all pertinent information concerning my prior employment and termination, including reasons of termination. I understand that misrepresentation or omissions of facts may cause dismissal. By signing below, I understand that my employment by Allied Care Corporation is subject to and contingent upon my completion of all employment related paperwork and providing all evidence of work eligibility, including but not limited to I-9 tax forms. I understand that my failure to comply with these requirements will result in the immediate termination of employment.
Digital Signature*
First Middle Last
Date*
MM slash DD slash YYYY
Optional - Upload Resume and/or References
Drop files here or

Accepted file types: pdf, jpg, Max. file size: 10 MB, Max. files: 4.
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School Name	City	Years Attended	Did you graduate?	Subjects Studied

CHHA/RN License Number	Date of Issue	Expiration Date	Issuing Authority

Start Date	End Date	Employer Name	Address	Salary	Position	Reason for leaving

Name	Relationship	Phone/Cell No.

Employment Application – Allied Care

CHHA Job Application Information

Personal Information

Emergency Contact Information

Employment Desired

Education History

License & Insurance Information

Former Employers

General Information

Authorization

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