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If you or your loved ones need care at home, in a hospital, hospice, nursing home, personal care home, assisted living facility, or any other location in Georgia, we’re here to help.

24-Hour Line: 470-641-6693

Email: info@angelssquadhc.com

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Employment Application

First name*

Last name*

Email*

Phone

Start Date

Address*

City*

State*

Date Available*

Zip Code*

Social Security No.*

Position Applied For*

Are you currently employed?

Multi choice

Yes

No

Multi choice

Part Time

Full Time

Preferred Shift

Desired Salary*

If No, are you authorized to work in the U.S.?

Multi choice

Yes

No

Have you ever been arrested?

Multi choice

Yes

No

If yes, please explain

Have you ever been convicted of a felony?

Multi choice

Yes

No

If yes, please explain:

EDUCATION

High School:

Did you graduate?

Yes

No

GED

Address

From

To

College:

Did you graduate?

Multi choice

Yes

No

Address:

Degree:

From

To

REFERENCES

Please lists three personal references

1

Full Name:*

Relationship

Company:

Phone*

Address*

2

Full Name:*

Relationship

Company:

Phone

Address

3

Full Name:

Relationship

Phone*

Address*

PREVIOUS EMPLOYMENT

Company:

Phone

Address

Supervisor:

Job Title:

Starting Salary Date:

Ending Salary Date:

Employed from:

From:

To:

Responsibilities:

May we contact for a reference?

Multi choice

Yes

No

Company:

Phone*

Address*

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Employed from:

to

Reason for leaving:

Responsibilities:

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to a position, I understand that false or misleading information in my application or interview may result in (1) my elimination from further consideration for a position or (2) my immediate discharge from Angel Squad Home Health, LLC. I understand that this company does not unlawfully discriminate and is an equal employment opportunity employer.

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