Careers Form

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Social Security Number

Street Address *

Address line 2

City *

State *

Postal / Zip Code *

Country *

Select Position(s) You Are Applying For

Direct Care Staff

Driver / Transporter

Office Staff

Personal Support Staff

Respite Care

Supported Employment Coaching

Are You Authorized To Work in the U.S.?

Yes

No

Have You Ever Been Convicted of A Crime?

Yes

No

If Yes, explain

Have You Ever Worked For Helping Heart, LLC?

Yes

No

If Yes, explain

High School *

Type of Diploma Received

Graduated? *

Yes

No

College

Type of Degree Received

Graduated?

Yes

No

Trainings Completed

CPR/AED

First Aid

Zero Tolerance

Core Competency

Assistance w/ Self Administration of Medication

Tuberculosis Test (TB Test)

HIV/AIDS Infection Control

List any other degrees, licenses or certifications *

Reference #1 - Full Name *

Company

Relationship *

Phone Number

Email Address

Reference #2 - Full Name *

Company

Relationship *

Phone Number

Email Address

Reference #3 - Full Name *

Company

Relationship *

Phone Number

Email Address

Company

Phone Number

Job Title

Supervisor Name

Start Date (From)

End Date (To)

Reason for Leaving

May we contact your previous employer?

Yes

No

List Job Responsibilities

Company

Phone Number

Job Title

Supervisor Name

Start Date (From)

End Date (To)

Reason for Leaving

May we contact your previous employer?

Yes

No

List Job Responsibilities

Company

Phone Number

Job Title

Supervisor Name

Start Date (From)

End Date (To)

Reason for Leaving

May we contact your previous employer?

Yes

No

List Job Responsibilities

Are you able to pass a Level 2 background screening?

Yes

No

Do you have a current Driver's License?

Yes

No

Do you have a current CPR/First Aid Certification?

Yes

No

Please attach your resume. Resume must be in an acceptable .doc or .pdf file format.

DISCLAIMER & SIGNATURE - I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature - Type Your Full Name *

Date

I understand that checking this box constitutes a legal signature confirming that I acknowledge the truthfulness of the information provided in this application.