EMPLOYMENT APPLICATION
Caregiver’s Home Solutions, LLC
80 Ferry Boulevard, Suite 202 Stratford, CT 06615
Phone (203) 870-9850 Fax (475)282-4293 Email hr@caregivershome.com
www.caregivershomesolutions.com
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INSTRUCTIONS: Please read the Applicant Note section below.
Complete all pages of this application.
Print clearly. Incomplete or illegible applications may not be accepted.
If more space is needed to complete any question, use Comments section or attach a
separate sheet.
Application will be valid for 180 days.
APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for
employment with Caregiver’s Home Solutions, a non-medical home care company headquartered in
Stratford, CT. This is not an employment contract. Please answer all appropriate questions completely
and accurately. False, misleading or incomplete statements during the interview and on this form are
grounds for terminating the application process or, if discovered after employment begins, terminating
employment. All qualified applicants will receive consideration and will be treated fairly and equally
throughout their employment without regard to race, color, religion, sex, national origin, age, disability,
or any other protected class status under applicable law. We may require testing for the presence of
illegal drugs in your body prior to employment.
PERSONAL INFORMATION
Today’s Date:
Positions(s) Applied For: _________________________________
Date of Birth: _____/_____/_______
Social Security Number: _____-_____-_______
Name:
Last
First
Middle
Current Address:
Street
Home Phone: (____) _____________
City
State
Zip Code
Work Phone: (____) _______________
Cell Phone: (____) ______________
Email: ______________________________
Driver’s License #/Exp. Date/State of Issue: _________________________________________
Other Names or Social Security Numbers (SSN) Previously Used:
Last
First
Middle
SSN
Last
First
Middle
SSN
Emergency Contact(s): ______________________
Name
(______)
_______________
Phone
Have you ever submitted an application here before? Yes / No If yes, when? _________
Have you ever been employed here before? Yes / No If yes, when? _________________
You have been given a copy of the job description for the position for which you have applied. Are you able to
perform the essential functions of the job for which you are applying with or without a reasonable
accommodation?
Yes / No
How did you hear about Caregiver’s Home Solutions?______________________________________________
Why are you interested in employment with us?
__________________
AVAILABILITY
NOTE: Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours
worked.
What date are you available to begin work? _______________
HOURLY
Mornings
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
Days
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
Evenings
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
LIVE-IN
Fill-In
Live-In
Fill-In
Yes/No
Sunday
Yes/No
Yes/No
Yes/No
Monday
Yes/No
Yes/No
Yes/No
Tuesday
Yes/No
Yes/No
Yes/No
Wednesday
Yes/No
Yes/No
Yes/No
Thursday
Yes/No
Yes/No
Yes/No
Friday
Yes/No
Yes/No
Yes/No
Saturday
Yes/No
Yes/No
Start time and end time is typically 9am. If you
cannot start or end at 9am please have further
discussion with H.R.

Are you willing to provide service to a client with a pet? Yes/No

If yes, which ones: ___ Cats ___ Dogs ___ ANY

Are you willing to provide service to a client who smokes? Yes/No
JOB RELATED SKILLS
Describe any training or life skills you have that apply to caring for a senior:
__________________
___________
Describe any work history you have that would apply to caring for a senior:
__________________
___________
What do you like (or think you would like) most about working with older adults?
___________
___________
What do you like (or think you would like) least about working with older adults?
___________
___________
EDUCATION
Please circle highest grade competed:
Grade School: 6 7 8
School Type
High School: 9 10 11 12
School Name
City, State
College: 13 14 15 16 16+
Major/
Subject
# Yrs
Attended
Graduate
High School
Y/N
Vocational/Tech
Y/N
College/University
Y/N
ADDITIONAL TRAINING, CERTIFICATIONS or RELEVANT SKILLS
Certifications: __________________________________________________________________
Training:
__________________________________________________________________
Equipment:
__________________________________________________________________
Cooking:
_____________________________________________________________
Grooming:
_____________________________________________________________
Language: (fluent only) _____________________________________________________
Hobbies/Interests: _________________________________________________________
WORK HISTORY
Your application will not be considered unless all questions in this section are answered
completely. Since we will make every effort to contact previous employers, the correct telephone
numbers of past employers are essential.
MOST RECENT EMPLOYER
Are you currently working for this employer? Yes / No
If yes, may we contact? Yes / No
____
Company Name
City
Dates Employed: From
State
(____)
Phone Number
to
Supervisor’s Name
Job Title
Duties
$
per
Salary (Hour, Week, Month)
Reason for Leaving
SECOND MOST RECENT EMPLOYER
____
Company Name
City
Dates Employed: From
State
(____)
Phone Number
to
Job Title
Supervisor’s Name
Duties
$
per
Salary (Hour, Week, Month)
Reason for Leaving
BUSINESS REFERENCES (Do not include relatives or personal friends)
Please complete all three references. Your application will not be considered unless three references are provided.
Since we will contact these references, please notify them in advance.
Full Name
Phone Number
H(
)
Best Time of
Day to Call
AM / PM
W(
H(
)
)
AM / PM
AM / PM
W(
H(
)
)
AM / PM
AM / PM
W(
)
AM / PM
1)
2)
3)
Relationship
Number of
Years Known
CERTIFICATION AND RELEASE
I certify that I have read and understand the Applicant Note on page one of this form and that the answers given
by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge
and are made in good faith. I understand that any false information, omissions or misrepresentations of facts in
this application may result in disqualification and dismissal and to such other penalties as may be prescribed by
law or employment agency policy and procedure. I authorize the company and/or its agents, including consumerreporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle
driving records. I authorize all persons, school, companies and law enforcement authorities to release any
information concerning my background and hereby release any said persons, schools, companies and law
enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this
company from any liability which might result from making such investigations. I also understand that the use of
illegal drugs is prohibited during my employment. If the company policy requires, I am willing to submit to drug
testing to detect the use of illegal drugs prior to and during employment.
I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT. I ALSO
UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY,
THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND CAREGIVER’S HOME SOLUTIONS, LLC, IS
TERMINABLE AT-WILL, SO THAT BOTH THE COMPANY AND I REMAIN FREE TO CHOOSE TO END OUR
WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY CHANGES IN THIS EMPLOYMENT
RELATIONSHIP MUST BE MADE IN WRITING.
APPLICANT SIGNATURE
DATE
EMPLOYEE’S COVENANT NOT TO COMPETE
Caregiver’s Home Solutions, LLC
80 Ferry Boulevard, Suite 202
Stratford, CT 06615
(203)870-9850
www.caregivershomesolutions.com
Whereas the Employee is considering accepting an AT-WILL employment position with the
Employer, CAREGIVER’S HOME SOLUTIONS, LLC (“Employer”) and
Whereas, Employee understands that Employer goes to great lengths and expense to obtain
clients, such clients providing places where Employer does business by placing Employees to
work and provide care at said locations; and
Whereas, Employee understands that Employer goes to great lengths and expense to obtain
qualified employees, such employees providing care at client locations or in Employer’s office
at the Employer’s direction; and
Whereas, in consideration for such AT-WILL employment, Employee acknowledges herein that
he or she shall not compete with the Employer in the following manner as described below.
1. Employer shall provide AT-WILL EMPLOYMENT to the Employee unless and until the
Employee’s services are no longer needed.
2. Employee shall not directly or indirectly solicit the clients or prospective clients of the
Employer directly or indirectly either during the term of the employment or for a period
of two years following the termination of the Employee’s employment.
3. Employee shall not directly or indirectly solicit the employees or prospective employees
of the Employer either during the term of the employment or for a period of two years
following the termination of the Employee’s employment
4. In the event the Employee accepts direct employment, either as employee or
independent contractor, with a client or prospective client of the Employer, the
Employee shall be liable to the Employer for liquidated damages in the amount of
$5,000.00 per client with whom the Employee engages as an employee or independent
contractor.
5. In the event the Employee accepts other direct employment, either as employee or
independent contractor, and solicits Employer’s employees or prospective employees
to move to the Employee’s new employer or as an employee of the Employee, the
Employee shall be liable to the Employer for liquidated damages in the amount of
$5,000.00 per employee with whom the Employee engages to join them as an
employee or independent contractor.
6. The parties agree that such amount of liquidated damages is agreed to in that it
represents the time, effort and expense that the Employer has incurred in obtaining its
client(s) or prospective client(s), employee(s) or prospective employee(s). For purposes
of this Agreement, a prospective client shall be identified as an individual or family to
whom Employer introduces the Employee for the purposes of determining Employee’s
suitability for assignment to client or prospective client. For purposes of this Agreement,
a prospective employee shall be identified as an individual who has applied for
employment with the Employer.
7. The Agreement shall inure to the benefit and obligations of the parties heir, assigns
and/or representatives.
8. This Agreement shall be construed under the laws of the State of Connecticut.
9. In the event the Employee breaches this Covenant, he or she shall be liable to the
Employer for the legal costs and fees incurred in enforcing this Agreement.
CERTIFICATION OF RELEASE:
I certify that I have read and understand the Agreement
I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT, OR AN OFFER OF
EMPLOYMENT. I ALSO UNDERSTAND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS
TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN MYSELF AND CAREGIVER’S HOME
SOLUTIONS, LLC, IS TERMINABLE AT WILL, SO THAT BOTH THE COMPANY AND I REMAIN FREE TO
CHOOSE TO END OUR WORK RELATIONSHIP AT ANY TIME FOR ANY OR NO REASON. ANY
CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING.
_____________________________________
APPLICANT (“EMPLOYEE”) SIGNATURE
__________________________
DATE
____________________________________
EMPLOYER SIGNATURE
__________________________
DATE
(Rev.2/14)
Employee Criminal Background Statement
1. Have you ever been convicted of a crime in a State or Federal court in any state?
Please circle:
Yes
No
If Yes, please describe in detail all felony and/or misdemeanor convictions
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Have you ever been subject to any decision imposing disciplinary action by a
licensing agency in any state, the District of Columbia, a United States possession
or territory or a foreign jurisdiction?
Please circle:
Yes
No
If Yes, please describe in detail_________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
I UNDERSTATED THAT ANY EMPLOYEE OF A HOMEMAKER-COMPANION AGENCY
HIRED ON OR AFTER OCTOBER 1,2006 WHO MAKES A FALSE WRITTEN STATEMENT
REGARDING SUCH PRIOR CRIMINAL CONVICTIONS OR DISCIPLINARY ACTION SHALL
BE GUILTY OF A CLASS A MISDEMEANOR.
____________________________________
Print Name
___________________________________
Employee Signature
________________
Date
CAREGIVER’S HOME SOLUTIONS, LLC  80 Ferry Boulevard, Suite 202  STRATFORD, CT 06615
P: 203-870-9850  F:475-282-4293  www.CaregiversHomeSolutions.com
Reference Release Form
Applicant Name: ______________________________________________________________
Applicant’s Authorization
I consent to and hereby authorize the below named former employer, to furnish any
requested reference information concerning me, including achievement, wage
history, performance, attendance, personal history, disciplinary information and
reason for separation of employment, relating to my employment with the former
employer. It is expressly understood that any information given is to be used for the
purpose of determining my acceptability for employment. I also hereby release the
below named former employer from all liability for damages or claims, including but
not limited to defamation, interference with contract, or prospective economic
advantage and negligence, I have or may have which arise or result from any
reference information provided pursuant to this authorization or any attempts to
comply with this information.
Applicant’s Signature_____________________________________________
Date: _______________________________
Record of Employment
Former employer: _________________________________________________________
Position held: __________________________ Dates employed:________________
Summary of essential duties: ________________________________________________
__________________________________________________________________________________
______________________________________________________________
Reason for leaving: _______________________________________________________
_______________________________________________________________________
Salary at termination:__________________
Eligible for rehire: ____ Yes ____ No
Please rate the following:
Excellent
Good
Average
Fair
Poor
Job
Knowledge
Productivity
Dependability
Attendance
Overall
Performance
Comments:_______________________________________________________________________
______________________________________________________________
Signature______________________
Title _________________ Date_______________
Reference Release Form
Applicant Name: ______________________________________________________________
Applicant’s Authorization
I consent to and hereby authorize the below named former employer, to furnish any
requested reference information concerning me, including achievement, wage
history, performance, attendance, personal history, disciplinary information and
reason for separation of employment, relating to my employment with the former
employer. It is expressly understood that any information given is to be used for the
purpose of determining my acceptability for employment. I also hereby release the
below named former employer from all liability for damages or claims, including but
not limited to defamation, interference with contract, or prospective economic
advantage and negligence, I have or may have which arise or result from any
reference information provided pursuant to this authorization or any attempts to
comply with this information.
Applicant’s Signature_____________________________________________
Date: _______________________________
Record of Employment
Former employer: _________________________________________________________
Position held: __________________________ Dates employed:________________
Summary of essential duties: ________________________________________________
__________________________________________________________________________________
______________________________________________________________
Reason for leaving: _______________________________________________________
_______________________________________________________________________
Salary at termination:__________________
Eligible for rehire: ____ Yes ____ No
Please rate the following:
Excellent
Good
Average
Fair
Poor
Job
Knowledge
Productivity
Dependability
Attendance
Overall
Performance
Comments:_______________________________________________________________________
______________________________________________________________
Signature______________________
Title _________________ Date______________