Last Name
First Name
Middle Name
What would you like to be called?
Email
Street
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Years There
Are you 16 years old or older? YesNo
Home Phone Number
Cell Phone Number
Alternate Phone Number
Maid ServiceMaid Service DriverNew ConstructionNew Construction Driver
Full TimePart Time
How did you find out about House Calls?
List below the last three employers, starting with the last one first.
Name of last employer
Starting Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997
Leaving Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997
Weekly Starting Salary
Weekly Ending Salary
Job Title
Name/Title of supervisor
Phone number
Reason for leaving
Give below the names of three persons not related to you. Whom you have known at least one year.
Full Name
Relationship To You
Phone Number
Years Aquainted
Do you have reliable transportation? YesNo
Do you have reliable child care? YesNoN/A
Currently or in the past, have you been convicted of or completed your sentence or parole for any crime? YesNo
if yes, please explain
Have you ever had any driving violations / tickets in the past? YesNo
Do you have a valid driver's license? YesNo
If I am hired by House Calls, LLC, I agree that I will be an at-will employee, which means that either House Calls, LLC or I may end my employment at any time with or without cause or notice. I agree that no written materials or verbal statements by House Calls, LLC will constitute an express or implied contract of continued employment and that this at-will relationship can only be modified in writing by House Calls' President. I agree that, if hired, I will obey House Calls, LLC rules, including treating confidentially and information I learn during my employment.
I am not a current user of illegal drugs and I agree that I will never work under the influence of drugs or alcohol.
There is nothing in my background what would cause a risk to House Call's clients, employees or property. I authorize House Calls to conduct reference checks, criminal and driving record checks, and other consumer report investigations. I release all parties from any liability from providing such information to House Calls in this regard. I understand that conviction of a crime will not necessarily disqualify me from employment. I understand that the nature and the relevance of the offense to the position(s) applied for will determine my elgibility for employment.
I certify that the information I have provided to House Calls is true and complete, I agree to notify House Calls immediately if I am later charged with any crimes or (if I am a driver) with a driving offense. I agree that any false information or omission allows House Calls to refuse to hire me, or to terminate my employement at any time.