Employment Application
ASI Home Care, INC
An Equal Opportunity Employer:
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital of veteran status, or any other legally protected status. In order to be considered an applicant, you must complete this form.
Complete all of the fields below and click submit form when finished.
General Information
Date of Application
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DD
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How did you hear about us?
Please select
Job Fair
Indeed
Website
Social Media
Referral
Other
New Choice
Please select
Position Applying for:
Home Care Aide
Family Caregiver
Heavy-Duty Cleaner
Supervisor
Name
Address
Phone
Email
Last 4 Digits of Social Security
Have you ever been employed by ASI?
Yes
No
If Yes, Dates of employment: (dd-mm-yyyy) to (dd-mm-yyyy)
Do any of your friends or relatives work here?
Yes
No
If yes, state full name and relationship.
Are you legally eligible for employment in this country? (Proof of citizenship or immigration status will be required upon employment)
Yes
No
Have you been convicted of a felony within the last 7 years?
Yes
No
Are you currently employed?
Yes
No
If you are currently employed, may we contact your employer?
Yes
No
Work Preferences & Availability
Are you looking for a full-time or part-time position?
Full-Time
I prefer Full-Time, but will accept Part-Time
Part-Time
Are you available to work weekends?
Available to work weekends
Unavailable to work weekends
Are you willing and able to service clients throughout the Chicagoland area (whether by driving or using public transportation)?
Yes
No
Education
Highest Level of Education
Please select
Elementary
High School
College
Other (Specify)
Please select
Specify:
Did you graduate?
Yes
No
Employment Experience
1. Current or Most Recent Employer
Job Title
Job Duties
Address
Telephone Number
Supervisor
Date Started
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DD
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YYYY
Date Ended
MM
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DD
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YYYY
Reason for Leaving
2. Current or Most Recent Employer
Job Title
Job Duties
Address
Telephone Number
Supervisor
Date Started
MM
/
DD
/
YYYY
Date Ended
MM
/
DD
/
YYYY
Reason for Leaving
3. Current or Most Recent Employer
Job Title
Job Duties
Address
Telephone Number
Supervisor
Date Started
MM
/
DD
/
YYYY
Date Ended
MM
/
DD
/
YYYY
Reason for Leaving
Regarding Employment Application for ASI, INC.
I certify that the information contained in this application and in any resume provided by me or any party representing my interests is correct and complete to the best of my knowledge. I understand that any false statements, misinterpretations, or omissions made by me on this application or any supplement to it, will be sufficient grounds for rejection of this application or discharge after employment.
I grant ASI, INC. (the "Company") the right to obtain pertinent information concerning me from former employers, educational institutions, and others, and I release all those providing or requesting such information from any liability that may arise by truthful disclosures or such investigations.
If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the Company reserves the same right to terminate my employment at any time with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the Company, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.
I understand it is the Company's policy not to refuse to hire a qualified individual with a disability
because of that person's need for a reasonable accommodation as required by the Americans with Disabilities Act.
I also understand that if I am hired, I will be required to provide proof of identity and legal work
authorization.
VIDEO & PHOTOGRAPHY RELEASE: I hereby consent to the use, reproduction, editing and/or broadcast by ASI, Inc. of all photographs, video recordings and audio recordings of me taken by or on behalf of ASI, Inc., from this day, without compensation to me. All negatives and positives, prints, video-recorded images, and audio recordings shall constitute the property of ASI, Inc. solely and completely.
Your signature acknowledges you have read and agree to the above.
Applicant Signature
Clear
Date
MM
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DD
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YYYY
Skills and personality assessment
Besides English, what other languages do you speak?
What are your strengths?
What are your weaknesses?
What did you like least about your last job?
What kind of personality do you work best with and why?
List six words that describes your character.
List any achievements/accomplishments that you are most proud of.
What irritates you about other people, and how do you deal with it?
What do you do to relax after a stressful day?
What would you do if you do not understand how to fill a form or perform task?
If a supervisor asked you do something that you disagree with, what would you do?
If you found out a co-worker committed fraud or is not performing his/her job, what would you do?
Describe how you would handle a situation where you were required to finish multiple tasks at the end of the day?
If you arrive to work at 8:03AM and you left at 12:43PM, what would be the total number of hours you woked?
Why should ASI hire you?
Alcohol Use
How many days a week (on average) do you consume an alcoholic beverage?
In the last 12 months, how many times did you miss work because you were drinking the night before?
In the last 12 months, what is the TOTAL number of times you had an alcoholic drink during your lunch break or work hours?
Illegal Drug Use/Experimentation
Which of the following drugs have you tried (even one time) in your entire life?
Marijuana
Speed
Crack
LSD (Acid)
Hash
Downers
Cocaine
Heroine
Mushrooms
None
P.C.P. (Angel Dust)
If you selected any of the above, when was the last time you took it?
How many times in all did you use an illegal drug during work hours in the last 2 years (even counting breaks and lunch)?
In the last 5 years, how many times in all did you buy or sell an illegal drug?
General Honesty
In the last 5 years how many jobs were you dismissed from?
When is the last time you took something from a store without paying for it?
In the last 5 years, did you keep any money that you found at the place where you work?
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