If you need help filling out this application form or for any phase of the employment process, please contact us and every effort will be made to accommodate your needs in a reasonable amount of time.

  1. Please read statement below.
  2. Complete all parts of the employment application.

Statement:
This application form is intended for use in evaluating your qualifications for employment.  This is not an employment contract.  Please answer all questions completely and accurately.  False or misleading statements during the interview and on this form are grounds for terminating the applicant process or, if discovered after employment, terminating employment.  All qualified applicants will receive consideration without discrimination because of marital status, race, age, creed, national origin, color, gender, sexual orientation, veteran's status or disability.  This policy applies to recruitment, hiring, placement, transfer, and all other personal actions.  Completed employment applications received by Quality Home Care Services, Inc. will be held on file for a period not to exceed 90 days.

 
Applicant Information
Today's Date
Position/Code
Desired Start
Desired Salary
First Name
Middle Name
Last Name
Telephone #
Cell Phone #
Email
Street Address
Apartment / Unit #
City
State
Zip Code
   
Are you legally eligible to work in the U.S.?     YES    NO
Are you 21 years of age or older?                     YES    NO
Have you ever been employed by Quality Home Care Services, Inc?
                                                                             YES    NO
If yes, please provide dates of:
   
Educational Background
High School  
Name of School
Dates Attended
Address
City,State,Zip
Did you graduate?
YES    NO
Type of Degree Received
Major Area of Study
Date Degree Received
College/University
Name of School
Dates Attended
Address
City,State,Zip
Did you graduate?
YES    NO
Type of Degree Received
Major Area of Study
Date Degree Received
Graduate School  
Name of School
Dates Attended
Address
City,State,Zip
Did you graduate?
YES    NO
Type of Degree Received
Major Area of Study
Date Degree Received
Vocational School  
Name of School
Dates Attended
Address
City,State,Zip
Did you graduate?
YES    NO
Type of Degree Received
Major Area of Study
Date Degree Received
   
Professional Licensure
Type of License
License #
State of Issue
Date of Issue
Date of Expiration
Type of License
License #
State of Issue
Date of Issue
Date of Expiration
   
Employment History
Work history must be completed without blanks regardless of information provided on resume.
1.
Employer
Job Title
Street Address
City/State/Zip
Telephone #
Supervisor
Hours worked per week
Start Date
End Date
Starting Salary
Ending Salary
   
Population Served:  (mark all that apply)
MR DD MH  SA  Not Applicable
   
Major Duties Worked Performed:
Reason for Leaving
May we contact this employer for reference information?
 
   
2.  
Employer
Job Title
Street Address
City/State/Zip
Telephone #
Supervisor
Hours worked per week
Start Date
End Date
Starting Salary
Ending Salary
   
Population Served:  (mark all that apply)
MR DD MH  SA  Not Applicable
 
Major Duties Worked Performed:
Reason for Leaving
May we contact this employer for reference information?
 
 
3.  
Employer
Job Title
Street Address
City/State/Zip
Telephone #
Supervisor
Hours worked per week
Start Date
End Date
Starting Salary
Ending Salary
   
Population Served:  (mark all that apply)
MR DD MH  SA  Not Applicable
 
Major Duties Worked Performed:
Reason for Leaving
May we contact this employer for reference information?
 
 
4.
Employer
Job Title
Street Address
City/State/Zip
Telephone #
Supervisor
Hours worked per week
Start Date
End Date
Starting Salary
Ending Salary
   
Population Served: 
(mark all that apply)
MR DD MH  SA  Not Applicable
 
Major Duties Worked Performed:
Reason for Leaving
May we contact this employer for reference information?
 
Military Experience
Have you ever served in the U.S. Armed Forces?  YES    NO
If yes, please specify:
 
Other Information
Do you have a valid Driver's License?  YES    NO
Driver's License #:   ST:  
Commercial Drivers License:
 
Have you ever been convicted of, or pleaded guilty to any crime?
YES NO   If Yes, where, for what, and date:
 
Are you currently free from illegal drug use?  YES    NO
 
Have you ever had a report of child abuse or neglect filed against you by DSS agency? YES    NO
If Yes, please explain:
 
CONVICTION OF A CRIME IS NOT AN AUTOMATIC BAR TO EMPLOYMENT ALL CIRCUMSTANCES WILL BE CONSIDERED
 
Give five professional work-related referenced.  References need to include the last two employers.
1.
Name:
Address:
Phone #:
Job Title:
Employer Name:
   
   
2.  
Name:
Address:
Phone #:
Job Title:
Employer Name:
   
   
3.  
Name:
Address:
Phone #:
Job Title:
Employer Name:
   
   
4.  
Name:
Address:
Phone #:
Job Title:
Employer Name:
   
   
5.  
Name:
Address:
Phone #:
Job Title:
Employer Name:
   
List memberships in professional, social, fraternal or civic organization that are related to the job for which you are applying:
 
Can you perform the essential duties of the position for which you are applying with or without reasonable accommodation? YES    NO
 
Are you fluent in a language other than English? YES    NO
If yes, please list:
 
Do you know sign language? YES    NO
 
Have you ever worked with Handicapped or Special Needs children?
YES    NO   If Yes, please explain:
 
Disclosure Statement
By this document, I understand that Quality Home Care Services, Inc. may utilize the services of a consumer-reporting agency as part of the procedure for processing my application for employment. I also understand if my application for employment is granted, Quality Home Care Services, Inc. may obtain further information through subsequent investigations by a consumer-reporting agency so as to update, renew or extend my employment. I understand a consumer reporting agency’s investigation may include information regarding my references, character, past employment, work habits, education, general reputation, personal characteristics, liens, mode of living, motor vehicle record, credit background, lawsuits, civil judgments, paid tax liens, accounts placed for collection and criminal conviction record investigation consistent with state law. I understand that The Fair Credit Reporting Act provides me with the right to request, in writing within a reasonable amount of time, a disclosure of the nature and scope of the investigation requested. I may also request a written summary of my rights under the Fair Credit Reporting Act as prepared by the Federal Trade Commission.
 
Applicant Consent to Release Information

I hereby consent to this investigation and authorize Quality Home Care Services, Inc. to procure a report on my background as stated above from a consumer-reporting agency. I understand such information may be obtained by direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. By signing this document, I am releasing any and all persons, companies, agencies, or others from liability resulting from the background investigation. I understand that the information requested below regarding date of birth, race and sex is for the sole purpose of gathering the above information accurately, and will not be used to discriminate against me in violation of any law.

I understand that prior to any negative employment action being taken (e.g., denial of employment, denial of promotion, suspension or termination) based, in whole or in part, on information obtained in the report, I will be provided a copy of the report and a description in writing of my rights under the Federal Fair Credit Reporting Act. I also understand that in the event that any negative employment action is taken based, in whole or in part, on information obtained in the report, I will be provided with a description in writing of my rights under state law. I understand if I disagree with the accuracy of any information in the report, I must notify Quality Home Care Services, Inc. within two days of my receipt of the report. If I notify Quality Home Care Services, Inc. within two days of the receipt of the report that I am challenging information in the report, Quality Home Care Services, Inc. will not make a final decision on my employment status until after I have had a reasonable opportunity to address the information contained in the report.

I hereby certify that all information contained on this application is true and complete. I authorize Quality Home Care Services, Inc. to contact all sources necessary to verify this information. I understand that any misstatement or omission is sufficient grounds for immediate discharge.

I understand that the relationship existing between employer and employees in North Carolina is called “employee at-will” This means that either party can terminate the employment relationship with or without cause and with or without notice.
 
Date:     Applicants Name:

  *required

 
Quality Home Care Services
3552 Beatties Ford Road
Charlotte, NC 28216
Phone: 704.394.8968
Fax: 704.934.8967