HomeAide Services, Inc.

First Name M.I. Last Name Street Address Work Telephone MobileTelephone Home Telephone When is the best time to call? Driver's License Number & State E-mail Address EDUCATION What years did you attend High School? What year did you graduate or obtain a G.E.D.? Years attended Did you finish? yes Course of Study or Degree 2nd College or University, City and State Years attended Did you finish? yes Course of Study or Degree Most Recent or Current Employer's Name Contact Name Employer's Address Employer's Phone Number Position and Description of Duties Employment Dates Salary or Rate Reason for Leaving Employment Previous Employer's Name Contact Name Employer's Address Employer's Phone Number Position and Description of Duties Employment Dates Salary or Rate Reason for Leaving Employment Previous Employer's Name Contact Name Employer's Address Employer's Phone Number Position and Description of Duties Employment Dates Salary or Rate Reason for Leaving Employment Previous Employer's Name Contact Name Employer's Address Employer's Phone Number Position and Description of Duties Employment Dates Salary or Rate Reason for Leaving Employment Reference's Name      Reference's Phone Number Reference's Address City, State Zip How do you know this person? Years Known Reference's Name      Reference's Phone Number Reference's Address City, State Zip How do you know this person? Years Known Reference's Name      Reference's Phone Number Reference's Address City, State Zip How do you know this person? Years Known PERSONAL INFORMATION do you have a reliable vehicle? yes can you read a map? yes Are you afraid of animals? yes Do you have house cleaning experience? yes Are you willing to work alone? yes Do you speak any language other than english? yes Are you currently employed? List Languages Spoken yes Have you applied to this company before? yes What areas are you willing to work? Raleigh Carrboro Durham Chapel Hill Hillsborough Cary Holly Springs Fuquay Varina Apex Garner Knightdale Wake Forest When will you be available to start work? Why are you interested in this position? Describe your cleaning experience? What daytime hours are you available? What are your top 3 priorities in life? select the days you are available Tuesday Wednesday Monday Friday Saturday Thursday By submitting this form, I hereby authorize HomeAide Services to use this information provided as an application for employment. "I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information."