* Required Information

EMPLOYMENT APPLICATION

IMPORTANT NOTE: This application is used to evaluate your skills and qualifications for employment with DL Green Enterpises, LLC dba Sunshiny Days. This is not am employment contract. Please answer all appropriate questions completely and accurately. False or misleading 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 throughout their employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. A complete background check, including DMV check, will be performed before the completion of the process if selected. You will also be required to take a drug screen before beginning employment.

PERSONAL INFORMATION

AVAILABILITY

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Shift

From:

To:

PREFERENCES

Please indicate the types of services which you are willing to provide:

Companionship Housekeeping (dust/vacuum) Errands/Shopping/Transportation
Meal Preparation Laundry/Ironing Personal Care
Acivities (games/crafts) Medication Reminders Dementia/Alzheimer's Care

*In order to be able to provide transportation or run errands, you will be required to have a valid driver's license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required.

JOB RELATED SKILLS

EDUCATION

School Type School Name City, State Major / Subject Number Years Attended Graduate
High School/GED
Vocational/Technical
College/University

*For Employment our minimum education requirement is either a GED or High School Diploma

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of the past employers are essential.

MOST RECENT EMPLOYER

SECOND MOST RECENT EMPLOYER

THIRD MOST RECENT EMPLOYER

SECURITY

As a condition of employment all employees must be "Bondable" and "Insurable".

REFERENCES (Do not include relatives)

Please complete all three (3) references. Your application will not be considered unless three (3) references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional references.

Full Name Phone Number Best time of Day to Call Relationship Number of years Known
CERTIFICATION AND RELEASE I certify that I have read and understand the important note on page one (1) 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 belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, 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 employment. 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. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between DL Green Enterprises, LLC dba Sunshiny Days and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

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