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Amoree Home Care
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Application for Employment
Please fill each form out and submit.
Last Name
First Name
Middle Name
Birthday
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Add answer here
Phone
Email
Applying for
Select position
Start Date
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Employment Information
Are you employed at the present time (If yes, please complete the following.)
Employer's Name
Employer's Address
How long have you been with this employer
If offered a position, when can you report for work?
If hired can you show proof of your legal right to work in the U.S.?
Yes
No
Have you ever been dismissed, or asked yo resign fom any position?
Yes
No
Have you ever been convicted of a felony, or misdemeanor w hich resulted in imprisonment? ( A yes answer to the above question does not neccessarily disqualify an applicant from employment .)
Yes
No
If yes to number 4 or 5 please explain:
Education
Employment Experience (List most recet experience first)
References
The following section is to be completed by applicant for an OFFICE POSITION:
How many words per minute?
Computer skills?
Macintosh
PC
Please provide computer and software knowledge below:
I certify that all statements made herein and on the enclosed resume are true and correct to the best of my knowledge. I authorize investigation of all statements herein recorded. I release from liablity all persons and organizations reporting information required by this application.dd answer here
Your Signature/Date
Clear
Next
BACKGROUND CHECK PERMISSION
The Background Check Permission Agreement (the "Agreement") is made and effective ths
Between (the "Employer") an individual with his main address at:
AND AMOREE STAFFING AGENCY LLC a corporation organized and existing under the laws of the, with its head office located at 2324 Greys PT RD Unit 11 Topping, VA 23169
In connection with my application to render services to the company, I hereby agree as follows:
1. GENERAL CONSENT TO BACKGROUND INVESTIGATION
2. CONSENT TO CONTACT PAST EMPLOYERS AND COMPANIES
3. CONSENT TO CONTACT GOVERNMENT AGENCIES
4. COOPERATION WITH INVESTIGATION
5. MISCELLANEOUS
Authorized Signature
Clear
Authorized Signature
Clear
Print Name and Title
Clear
Print Name and Title
Clear
Submit
Our Services
Service Information
Accompany to Doctor Visits
1 hr
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Home Visit
1 hr
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Medication Reminders
1 hr
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Grocery Shopping & Errands
1 hr
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Meal Preparation
1 hr
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Discharge Assistance/Prescription Pick Up
1 hr
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Socializing
1 hr
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Laundry and Linens
1 hr
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Encouraging Engagements
1 hr
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Report and Record Information Relevant to Case
1 hr
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Keep Seniors Safe
1 hr
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Respite for Families
1 hr
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Bathing and Dressing
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Incontinence Care/Tolieting
1 hr
100 US dollars
$100
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Managing Behaviors
1 hr
100 US dollars
$100
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Mobility Assistance
1 hr
100 US dollars
$100
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Assisting with Activities of Daily Living
1 hr
100 US dollars
$100
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Supplemental Hospice Support Services
1 hr
100 US dollars
$100
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Couples Care
1 hr
100 US dollars
$100
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Specialized Equipment
1 hr
100 US dollars
$100
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Advanced Care Management
1 hr
100 US dollars
$100
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Awake Overnight Care
1 hr
100 US dollars
$100
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