From the moment of diagnosis, we are here to help

(856) 344-7982

Fax: (856) 344-7984

614 S. White Horse Pike

Somerdale, NJ 08083

serenityhhcns@gmail.com

Employment Opportunities


Option 1:


Download Instructions


PDF:

1. Right click HERE and choose Save Link As or Save Target As

2. Fill in ALL of the form's fields and answer ALL questions.

3. Save the completed PDF form.

4. Email the completed PDF to serenityhhcns@gmail.com


Microsoft Word Document:


1. Right click HERE for Word 97 - 2003 document or HERE for Word 2010 and choose Save Link As or Save Target As

2. Fill in ALL of the form's fields and answer ALL questions.

3. Save the completed Word document form.

4. Email the completed document to serenityhhcns@gmail.com


Option 2:


1. Fill in All fields below and answer All questions.

2. Click the Submit button at the end of the application.



Date


Social Security Number


Date of Birth


First Name


Last Name


Home Phone #


Work Phone #


Mobile Phone #


Email


Maiden Name


Previous Married Name(s)


Address: Line 1


Address: Line 2


City


State


Zip Code


Current School or Employer


Applying for Full/Part Time


Name, Address and Phone Number of Nearest Relative or Friend



How did you hear about Serenity?


Who do you know that is a current or a previously listed employee with Serenity?



JOB PREFERENCE CHECK ONLY THE AREAS IN WHICH YOU HAVE EXPERIENCE:


 Childcare        Eldercare

If Childcare, what age preference


PLEASE CHECK YES OR NO FOR THE FOLLOWING: IF YES, PLEASE EXPLAIN BELOW


Live-In Only

 Yes        No

Live-Out Only

 Yes        No

Can you swim?

 Yes        No

Do you smoke?

 Yes        No

If yes, how much per day?


Do you have a car?

 Yes        No

If yes, what type?


Are you willing to work with dog(s) in the home?

 Yes        No

Are you willing to work with cat(s) in the home?

 Yes        No

Are you willing to work with other types of pets in the home?

 Yes        No

If no, please explain?


EDUCATIONAL INFORMATION

Check the last LEVEL of education that you have completed:

 Some High School        High School        GED
 College        Post Graduate

High School - Did you graduate?

 Yes        No

If no, what is the highest grade you have completed?



School/University Name


Major


Dates Attended (from - to):


Degree Earned


EMPLOYMENT HISTORY

LIST ALL EMPLOYMENT INCLUDING CHILDCARE/COMPANION CARE FOR THE LAST 3 YEARS, STARTING WITH YOUR CURRENT OR LAST JOB. ALSO, LIST VOLUNTEER OR FAMILY EXPERIENCE WITH CHILDREN OR ADULTS. YOU MAY NOT USE FAMILY MEMBERS AS A REFERENCE.



(1) Dates of Employment (from to):


Days Worked:

 Sunday
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday

Hours Per Day


Company or Family Name


Supervisor and Title


Address Line 1


Address Line 2


City


State


Zipcode


Phone #


Email


Relationship to you


Number of children/adults cared for


Job Title and Duties


Beginning Salary


Ending Salary


Reason for leaving this position:


Comments


(2) Dates of Employment (from to):


Days Worked:

 Sunday
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday

Hours Per Day


Company or Family Name


Supervisor and Title


Address Line 1


Address Line 2


City


State


Zipcode


Phone #


Email


Relationship to you


Number of children/adults cared for


Job Title and Duties


Beginning Salary


Ending Salary


Reason for leaving this position:


Comments


(3) Dates of Employment (from to):


Days Worked:

 Sunday
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday

Hours Per Day


Company or Family Name


Supervisor and Title


Address Line 1


Address Line 2


City


State


Zipcode


Phone #


Email


Relationship to you


Number of children/adults cared for


Job Title and Duties


Beginning Salary


Ending Salary


Reason for leaving this position:


Comments


LEGAL HISTORY

Do you have the legal right to work in the USA for any employers?

 Yes        No

Since the age of eighteen, have you been convicted of a crime?

 Yes        No

If yes, please explain?


***Note: A conviction will not necessarily bar you from being referred. Conviction will be judged on its own merits with respect to time, circumstance, and seriousness of offence.



Have you had any auto accidents within the last 5 years?

 Yes        No

If yes, please explain?


Have you had any traffic tickets within the last 5 years?

 Yes        No

If yes, please explain?


Drivers License Number


State License is issued


Insurance Company Information:

Name


Address Line 1


Address Line 2


City


State


Zipcode


PERSONAL REFERENCES

**Personal References must not be the same business references and must not be related to you in anyway.**



Reference 1

Name


Relationship


Address Line 1


Address Line 2


City


State


Zipcode


Phone #


Work #


Mobile #


Reference 2

Name


Relationship


Address Line 1


Address Line 2


City


State


Zipcode


Phone #


Work #


Mobile #


Reference 3

Name


Relationship


Address Line 1


Address Line 2


City


State


Zipcode


Phone #


Work #


Mobile #


How did you learn about Serenity?
 Caregiver          Client      
 Publication        Word of Mouth      

Referred by


I affirm that all information provided by me to “Serenity” is correct to the best of my knowledge.



Signature


Date


Authorization for Release of Information

Background Check Disclosure


As part of the employment process, Serenity Home Healthcare and Nursing Solutions, LLC. hereby known as (“the Company”) may obtain a consumer report and/or Investigative Consumer Report. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for the purposes of employment only, a Consumer Report may be made which may include information about your credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided in the event the Report contains information regarding your character, general reputation, personal characteristics, or mode of living.


Authorization and Release


During the application process and at any times during any subsequent employment, I hereby authorize U.S. Information Search on behalf of The Company to procure a Consumer Report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. This report may include Criminal Records, Credit Reports, Driving Records, Past Employment or Education Verifications and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate Disclosure of the nature and scope of the background verification; to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living. I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility from doing so. This authorization and consent shall be valid in original, fax or copy form.


Applicant/Employee Name


Date


Date of Birth


Social Security Number


Driver's License Number


Address Line 1


Address Line 2


City


State


Zipcode


California and Minnesota Applicants Only: Please check here to have a copy of your consumer report sent to you from USIS. Mail a copy of this request with this box checked off to U.S. Information Search, 15 North Mill Street, Nyack, NY 10960. Include in the envelope a copy of your Driver’s License (for Identification) and a $5.00 check or money order (for processing) and an address where you would like the report mailed to.

 Yes

Oklahoma Applicants Only: Please check here to have a copy of your consumer report sent to you from USIS free of charge. Mail a copy of this request with this box checked off to U.S. Information Search, 15 North Mill Street, Nyack, NY 10960. Include in the envelope a copy of your Driver’s License (for Identification) and an address where you would like the report mailed to.

 Yes

Do You Have Any Experience In (provide additional comments below)



Attention Deficit Disorder

 Yes        No

Physically Handicapped

 Yes        No

Twins/Multiple Births

 Yes        No

Toilet Training

 Yes        No

Behavior Disorders

 Yes        No

Mentally Handicapped

 Yes        No

Mildly Ill Child

 Yes        No

24 Hour Live-In Care

 Yes        No

Learning Disabilities

 Yes        No

Care When Parent is at Home

 Yes        No

New Mother/baby care (0 to 6 weeks)

 Yes        No

Foreign Language

 Yes        No

Computer Skills

 Yes        No

Alzheimer's

 Yes        No

Autism

 Yes        No

Cerebral Palsy

 Yes        No

Comments


Are You Currently Certified In (provide additional comments below)



Infant/Child CPR

 Yes        No

Adult CPR

 Yes        No

Community CPR

 Yes        No

First Aid

 Yes        No

CNA or HHA

 Yes        No

Patient Care Courses

 Yes        No

Teaching Certificate

 Yes        No

Child Care

 Yes        No

Comments




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