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Employment History (most recent first):
Previous Employers (please list 2-3):*
Dates Employed Employer Name Employer Address Phone Salary Pay Rate Duties Performed Reason for Leaving
Professional References (please list 2-3):*
Name Where did you work with this individual? Phone Years Known (Office Use Only)
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I CERTIFY that the information contained in this application is correct to the best of my knowledge, and I understand that any misstatement or omission of information is considered willful misconduct and is cause for ending the hiring process or termination of employment. I authorize verification of information provided on this application; and authorize the references listed above to give HomeAides all pertinent information concerning my previous employment; and release all parties from all liability for any damage that may result from furnishing the same to HomeAides. I further agree that either I or HomeAides may terminate my employment with or without cause and with or without prior notice, at any time. I understand that if hired, work hours are not guaranteed in any way but dependent on consumers/client needs and/or specific requests as well as case logistics. I understand that I will be required to submit to a drug test in accordance with HomeAides drug testing policy. I understand that I must submit to multiple background/clearance checks as a condition of employment with this company. Failure to submit to such a check will result in ineligibility for hire or my employment being terminated. HomeAides is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with HomeAides depends solely on your qualifications.
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Dates Employed	Employer Name	Employer Address	Phone	Salary Pay Rate	Duties Performed	Reason for Leaving

Name	Where did you work with this individual?	Phone	Years Known	(Office Use Only)