Before you begin

Application Requirements

Name: Mount Hope Home Care
Address: 231 Chestnut Street, Suite 214, Meadville, Pennsylvania 16335
Telephone: (814) 732-0017

Required items are marked with a *. Each section must be completed before you can continue to the next step.

After the final step, submit the application and confirm that you see "Submission Complete!". If you have trouble completing the application, please contact Mount Hope Home Care at (814) 732-0017.

Important: To be considered for employment you must have a valid ID Card.

I have read and understand the information above, including the identification requirement.

Positions

Nursing Home Alternative- Provides care to seniors in shared housing (ie. Brookside Homes).

In-Home Caregiver- Provides care to seniors in individual homes.

Check the positions you are applying for. *
Nursing Home Alternative Caregiver In-Home Caregiver Other

Personal Information:

How did you hear about us? (relative, friend, customer, etc. - include their name)

Salutation:*(Mr., Mrs., Ms., Miss)

First Name: *

Middle Initial:

Last Name:*

Address 1: *

Address 2:

City: *

State: * (Use two letter abbreviation such as PA, OH, NY)

Zip Code:*

Phone:* (999-999-9999)

Cell Phone: (999-999-9999)

Email:

May we contact your current employer?*

Yes

N/A

Can you lawfully work in the USA? *

Yes indicates you are not prevented from lawfully becoming employed in this country because of Visa or Immigration Status. Proof of citizenship or immigration status will be required upon employment.

Yes

Date available to start:* (MM/DD/YYYY)

What is your desired salary range?* (dollars per hour)

Employment History

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which include race, color, religion, gender, national origin, disabilities, or other protected status. Any or all, of these employers may be contacted to verify employment information.

Employer 1

Employer:

Address 1:

Address 2:

City:

State: (Use two letter abbreviation such as PA, OH, NY)

Zip Code:

Phone: (999-999-9999)

Fax: (999-999-9999)

Job Title:

Supervisor:

Reason for Leaving?

Start Date: (MM/DD/YYYY)

End Date: (MM/DD/YYYY)

Starting Hourly Rate (dollars per hour) or Salary:

(If entering salary, indicate for week, month, or year)

Ending Hourly Rate (dollars per hour) or Salary:

(If entering salary, indicate for week, month, or year)

Employer 2

Employer:

Address 1:

Address 2:

City:

State: (Use two letter abbreviation such as PA, OH, NY)

Zip Code:

Phone: (999-999-9999)

Fax: (999-999-9999)

Job Title:

Supervisor:

Reason for Leaving?

Start Date: (MM/DD/YYYY)

End Date:(MM/DD/YYYY)

Starting Hourly Rate (dollars per hour) or Salary:

(If entering salary, indicate for week, month, or year)

Ending Hourly Rate (dollars per hour) or Salary:

(If entering salary, indicate for week, month, or year)

Employer 3

Employer:

Address 1:

Address 2:

City:

State: (Use two letter abbreviation such as PA, OH, NY)

Zip Code:

Phone: (999-999-9999)

Fax: (999-999-9999)

Job Title:

Supervisor:

Reason for Leaving?

Start Date:(MM/DD/YYYY)

End Date:

Starting Hourly Rate (dollars per hour) or Salary:

(If entering salary, indicate for week, month, or year)

Ending Hourly Rate (dollars per hour) or Salary:

(If entering salary, indicate for week, month, or year)

Nursing Experience

Check here if you have 2 or more years of experience

Professional References

Professional Reference #1:

Name:*

Phone Number:*

Relationship:*

Professional Reference #2:

Name:*

Phone Number:*

Relationship:*

Personal References

Personal Reference #1:

Name:*

Phone Number:*

Relationship:*

Personal Reference #2:

Name:*

Phone Number:*

Relationship:*

Education

Highest Level of Education Completed:*

GED High School Diploma

Undergraduate College Graduate College

Other:

Other relevant education, specialized training, second languages, or other qualifications

Certified Nurses Aid Expiration Date: (MM/DD/YYYY)

Certified Home Health Aid Expiration Date: (MM/DD/YYYY)

CPR Expiration Date: (MM/DD/YYYY)

First Aid Expiration Date: (MM/DD/YYYY)

Additional Information

Do you have a VALID Driver's License and/or I.D. Card?*

Yes

Do you have RELIABLE Transportation?*

Yes

Are you willing to work split shifts?*

Yes

Criminal Record Check

A CRIMINAL HISTORY CHECK IS MANDATORY FOR ALL APPLICANTS

and requires maiden name, aliases, and date of birth information.

Have you ever plead guilty to or been convicted of any felony, or misdemeanor?*

(Exclude summary offenses)

Yes

If Yes, explain in detail:

Maiden Name or Aliases (if any)* If none, enter NONE

Date of Birth*

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I hereby consent that all outstanding debts owed to Mount Hope Home Care may be deducted from any paycheck, including paychecks received after termination of employment.

Signature of Applicant *

By entering your full name here, you certify that all statements on this application are true and complete

Application Requirements

* Required

Positions

Personal Information:

Employment History

Employer 1

Employer 2

Employer 3

Nursing Experience

Professional References

Personal References

Education

Help Your Scheduler Get to Know You!

Additional Information

Criminal Record Check

Applicant's Statement