Please complete the Online form below.

To be considered for employment with EJQ Home Health Care, Inc. please fill out the following Application

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Name:

Address:

Address:

City:

Zip / Postal Code:

Phone: Cell Phone:

Work history

Please include Employer name,Address, phone, employment dates and ending pay from your 3 most recent employers. Last one first: #1 #2 #3

Education last one completed

Have you ever been previously employed with us?

If yes, dates employed with us

Position desired $ Salary desired $

List below all the General Primary times YOU ARE and WILL BE available for client placements.

Please be as accurate as possible. The availability you list below will be the times you will be asked to fulfill after hiring. Your availability needs to be listed accurately for us to even consider you for employment. If your availability changes after hiring you must inform us immediately and before your next schedule is issued, any significant changes may result in your no longer being able to be placed with a client and their for limited to no scheduling may be done for your new availability.

We understand and acknowledge you may have personal and family responsibilities such as Drs. Appointments and the like in which case you may not be available during these certain times on these certain days during your employment.

Please tell us about any and all changes at time of hiring and as any Days Off may be needed as necessary.

Please be as accurate as possible we will Try to schedule you during the times you list below but you may be placed as soon as possible before or after according to the availability you list and our clients needs.

Time available refers to the hours during the day you can work.

List below the times of day you are available for placements.

Mondays Time available

Tuesdays Time available

Wednesdays Time available

Thursdays Time available

Fridays Time available

Saturdays Time available

Sundays Time available

Time Type desired

Medical, Vision, and Dental benefits are available with Full time employment and more then 25 hours a week.

Have you ever been convicted of felony?

If Yes Include, Charge, Date, State and County where convicted:

Explain Felony here:

Previous conviction for certain Felony offenses may or may not result in Employment ineligibility according to the

State of Ohio Home Health Care Regulations.

The not so fine legal print:

I do authorize this company

E.J.Q. Home Health Care, Inc.

And any acting agents thereof to perform a background criminal check and fingerprinting.

I hereby certify that the answers given by me to all of the questions contained on this online application form filled in are true, accurate, and precise.

If employed by E.J.Q. Home Health Care, Inc.

I agree to, and I will comply with any and all the rules and regulations thereof.

I release previous employers and E.J.Q. Home Health Care, Inc. from all liability for any damage caused by releasing any and all said information.

I understand that any employment relationship with E.J.Q. Home Health Care, Inc. is At Will, which means, that the employee may resign with two weeks notice and that E.J.Q. Home Health Care, Inc. may discharge the employee at any given time, with or without a detailed explained cause.

Any termination can and may be done Within the local guidelines of The U.S. Equal Employment Opportunity Commission and State of Ohio Home Health Care Regulations, without prejudice or Discrimination to any individual for any reason on the basis of race, color, religion, sex, national origin, disability, or age, being solely do to an inability to provide client placement for any said individual at the time of hiring or termination or the employee having not satisfied any of all of the terms of the employment requirements.

Thank you.

We look forward to reviewing your application here at

E.J.Q. Home Health Care, Inc.

Answer below if you agree or not to the terms of this application

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