Empress Home Care Employment Application

Employment Application Form:

Thank you for filling out your application. Please note that we will receive your application immediately after submission. There is no need to call us after submission. If we are interested, we will contact you. Please be sure to read the job description of the job before applying.
Personal Information:

Please fill out all information below.
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
E-mail*
Birth Date*

MonthDayYear
Are You a U.S. Citizen?

YesNo
As of today, Are you at least 18 years old and older?

YesNo

Availability*

	Sun	Mon	Tue	Wed	Thrus	Fri	Sat
Morning 7a to 3p
Evening 3p to 11p
Overnight 11p to 7a
Admin Hours 9a to 5p
Mixed Hours/Anytime

Conditions I am willing to work with*

	YES	NO	ON CERTAIN OCCASIONS
CHILDREN
SMOKERS
PETS
CATS
DOGS
ALTERNATE WEEKENDS
KOSHER KITCHEN
WEEKENDS ONLY
MORNINGS ONLY
LIVE-IN
OVERNIGHTS
AFTERNOONS
LIGHT DUTY
HAS CAR
SPEAKS ENGLISH
SEEKING EMPLOYMENT
LIVE IN ON WEEKENDS ONLY

Employment Desired:

Please fill out all information to the best of your knowledge. We have to contact at least 1 previous employer.
Please visit our indeed.com

page here to see our open positions.
***Please note, if you applying for the Weekend Coordinator, In-Home Care Floater, or In-Home Care Aid, you will need to complete a competency test upon submission of this application. Be sure to set aside the time to complete this.

The competency test will take 30-45 minutes to complete***
What state do you live in or applying for?*

ArizonaPennsylvania (Pittsburgh and surrounding areas)Pennsylvania (Philadelphia and surrounding areas)
Position you are applying for?*

Human Resources (In charge of all hiring and HR functions)Admin Assistant (Will assist CEO with duties and activities)Marketer (Go out and promote the business to bring in clients)Nurse (Performs all nursing funtions)Weekend Coordinator (Will be in charge for all functions such as scheduling, call offs, home visits, and etc. when the office is closed including holidays)In Home Care Floater (MUST have an open and available schedule as well as a reliable vehicle and be available at all times especially on short notice)In Home Care Aid (Works inside the home of the clients and performs ADL's and assist with companionship)
Have you lived in Pennsylvania for more than 2 years? [You will need to prove this if your drivers license issue date is less than 2 years as per the PA Regulation 611.52 (a) (d).]

YesNo
Do you understand that as a Floater, you will BE EXPECTED to travel UP TO 60 miles to start services for a client or assist with a call off or no show if needed and you will need to have your own vehicle and reliable transportation. You must also have an open and available schedule. If your answer is no, please pick another position.*

YesNo
Do you understand that as a Marketer, you will BE EXPECTED to be out of the office 95% of the time promoting the business from place to place such as hospitals and other senior homes. You will also need to be very organized and have reliable transportation. If your answer is no, please pick another position.*

YesNo
Do you understand that as an Weekend Coordinator, you will BE EXPECTED to take calls, do surprise home visits, and solve problems when the office is closed during the Weekends from 5pm Friday to 9am Monday morning and on Holidays?*

YesNo
Do you have your PA police check clearance certificate? Do not complete the volunteer version unless you plan to volunteer.(https://epatch.state.pa.us/Home.jsp)*

YesNo
Do you have your PA Physical WITH COMPLETED 2 step TB Test?*

YesNoI have my physical but not my TBI have my TB but not my Physical
Do you have your PA Child Abuse Check Completed? (https://www.compass.state.pa.us/maintenance/pages/)*

YesNo
Do you have you PA Fingerprint clearance certificate?*

YesNoNot needed since I resided in PA for more than 2 years and I can provide proof
Do you have your Arizona Central Registry Clearance check?*

YesNo
Do you have Your Arizona Article 9 Fingerprint Card?*

YesNo
Do you have your Arizona Prevention and Support Certificate?*

YesNoI do but it expired
Do you have your First Aid/CPR Training card?*

YesNoI do but it expired
Do you have your 39 month Arizona Driving Abstract Completed? (https://servicearizona.com/motorVehicleRecord)*

YesNo
For Arizona, Do you have any additional trainings valid and completed?*

Introduction to Developmental DisabilitiesMedication BasicsIncident ReportingPositive Behavior SupportOther
As of today, do you have your own RELIABLE transportation? (A vehicle that can get to back and forth to work?)*

YesNo
If you do not have your own vehicle, Do you live on a bus line or have or reliable means to get yourself to and from work on your own without any issues? (If you answered no to this question, please do not continue the application.)*

YesNo
Do you understand that you can NOT start nor be put on the schedule until you have your clearances completed? (Police Check, Child Abuse, Physical WITH COMPLETED 2 step TB and necessary trainings?) It is fully YOUR RESPONSIBILITY to complete your clearances and trainings. If you have answered no to this question, please do not continue the application*

YesNo
Date You Can Start*

MonthDayYear
Salary Desired*
Have You Worked Here Before?*

YesNo
Do you fully understand and acknowledge that a client/consumer/patient/person receiving services in any group setting is NEVER to be left alone unless otherwise stated in their ISP/IEP plan? If your answer is no, please DO NOT continue the application.*

YesNo
Education:

Please fill out all information to the best of your knowledge. We will verify all information.
High School*
Name of High School Attended
Number of Years Attended*
Graduated?*

YesNoStill in SchoolDropped OutOther
College
Name of College/University Attended
Number of Years Attended
Graduated?

YesNoStill in SchoolDropped OutOther
Area of Study/Degree
Graduate School
Name of Graduate School Attended
Number of Years Attended
Graduated?

YesNoStill in SchoolDropped outOther
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Graduated?

Yes
Area of Study/Degree
Skills/Qualifications:

This section is for any addition skill or qualification you would like to tell us about. This section is optional.
Skills
List any relevant skills
Qualifications
List any relevant certifications or qualifications
Current Employment:

Please fill out all information to the best of your knowledge. We have to contact at least 1 previous employer but verify all previous employment.
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Starting Salary*
Current Salary*
Reason for Leaving?*
Start Date*

MonthDayYear
End Date

MonthDayYear
Date
May We Contact?*

YesNo
Previous Employment:
Previous Employer
Name of Previous Employer
Position
Starting Salary
Ending Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Previous Employer
Name of Previous Employer
Position
Starting Salary
Ending Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Professional References:

Please only list references that are previous supervisors or Human Resource Managers. You are allowed one personal reference. You will put your references here but if you move on to the next module, you will be required to do 3 references letters online. Please make sure the reference information is not only valid but the numbers and addresses are updated.
Professional Reference 1*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email
Professional Reference 2*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email
Personal or Professional Reference *
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email
Cover Letter & Resume (Optional):
Cover Letter

Upload a File

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Resume

Upload a File

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Enter the message as it's shown*
How do you handle medical emergencies?*
How do you maintain the privacy and dignity of your patients?*
In what ways have you advocated for the well being of your clients?*
Describe a time when one of your patients refused care. How did you handle it?*
Describe a time you resolved a conflict with your patient's family. What was the problem?*
What was the outcome of the above question?*
Imagine that your shift has ended but your relief was 15 minutes late. What would you do?*
Why have you chosen to work in home care?*
What specialties or interest do you have in regards to home care?*
Talk about a typical day at your previous workplace?*
Describe your experience with elderly patients?*
In as much detail as possible, describe the process for moving a patient from thier wheelchair into a bed.*
How do you keep your client's family informed about their progress?*
Send Application:

Please make sure all the information is truthful and correct. You can send your resume if you choose but your resume can not be a replacement for your application.
By clicking the submit button below, I certify that all of the information provided by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. By signing below, you are giving Empress Home Care permission to run your background check and verify all the information above.

Please note, based on your answers, you will be prompted to take the competency test. If you do not see the competency test, you were not chosen to move forward in the process.
Name*

First NameLast Name
Signature*

Clear
Should be Empty:

Employment Application Form:

Personal Information:

Employment Desired:

Please visit our indeed.com

page here to see our open positions.

Education:

Skills/Qualifications:

Current Employment:

Previous Employment:

Professional References:

Cover Letter & Resume (Optional):

Send Application: