Application for Employment: Admin/Support │ Tri-County Home Care of Florida, Inc.

1Personal Information

2Application Information

3Education

4Employment History

5Skills & Qualifications

6Personal Verification Information

7Document Uploads

8Attestation

Your application will not be complete until you have accessed the pre-screening documents located either on the Application Process page under Careers or Pre-screening Documents page under Admin/Office page.

You may continue with this application and then complete the pre-screening documents. However, we advise that you complete the pre-screening documents prior to you online application.

Today's Date

PERSONAL INFORMATION

Your personal information will be kept confidential.

Name

First

Last

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone Number

Alternate Phone Number

Confirm Email

You must have a valid email to complete this application.

EMERGENCY CONTACT

In case of emergency, please notify the following.

Name

First

Last

Relationship

Spouse/Partner
Parent
Adult Child
Family Member
Friend

Emergency Contact Phone

Emergency Contact Email

LEGAL HISTORY

Conviction of a crime will not necessarily disqualify you from employment.

Have you ever been convicted of a felony or misdemeanor? *

Do you have a legal right to work in the U.S? *

POSITION INFORMATION

Desired Salary

Availability *

Full-time
Part-time

Are you currently employed?

Are you authorized to work in the US? *

If hired, which date will you be available to begin work?

PROFESSIONAL & BUSINESS REFERENCES

Please list 3 professional references not related to you. If you don’t have professional references, please skip to PERSONAL REFERENCES.

Reference #1 Name

First

Last

Occupation

Nature of Relationship

ex. past supervisor or employer

Phone

Reference #2 Name

First

Last

Occupation

Nature of Relationship

ex. past supervisor or employer

Phone

Reference #3 Name

First

Last

Occupation

Nature of Relationship

ex. past supervisor or employer

Phone

Personal References

Do not list family members

Personal Reference #1 Name

First

Last

Relationship

Phone

Personal Reference #2 Name

First

Last

Relationship

Phone

EDUCATION

High School

Name of High School

City, State or Country

High School Degree? *

Year of Graduation *

College or University

Have you attended community college or a four-year college? *

Name of Institution

City, State or Country

Associates Degree?

Bachelors Degree?

Year of Graduation

Major Course of Study

Trade School

Name of Institution

Trade

Year of Completion

Employment History

Please list your employment history over the last two-five years.

Company #1

Company Name

City, State or Country

Your Job Title/Position

Direct Supervisor

First

Last

Phone

Is this your current employer?

Start Date of Employment

End Date of Employment

Starting Salary

Ending Salary

Major Responsibilities

Reason for Leaving?

New Position
Involuntary Resignation
Termination
Temp/Employment
Internship
Other

May we contact this employer?

If you do not want us to contact this employer, please explain.

Company #2

Company

City, State or Country

Phone

Your Job Title/Position

Direct Supervisor

First

Last

Start Date of Employment

End Date of Employment

Starting Salary

Ending Salary

Major Responsibilities

Reason for Leaving?

New Position
Involuntary Resignation
Termination
Temp/Employment
Internship
Other

May we contact this employer?

If you do not want us to contact this employer, please explain or type N/A

Company #3

Company

Direct Supervisor

First

Last

City, State or Country

Your Job Title/Position

Phone

Start Date of Employment

End Date of Employment

Starting Salary

Ending Salary

Major Responsibilities

Reason for Leaving?

New Position
Involuntary Resignation
Termination
Temp/Employment
Internship
Other

May we contact this employer?

If you do not want us to contact this employer, please explain.

SKILLS & QUALIFICATIONS

Skills

Related skills. Please list any information that you believe will be helpful in consideration.

Qualifications

Related qualifications: Please list any information that you believe will be helpful in consideration.

Foreign Language Proficiency

Spanish
French
Haitian Creole
Italian
Portuguese
Russian
ASL
Other

Check all that apply.

If other language, please list.

Objectives

Provide a brief description of yourself, including short and long term occupational objectives.

PERSONAL VERIFICATION INFORMATION FOR BACKGROUND CHECK

Your personal information will be kept confidential.

Name

First

Last

Have you ever used another name professionally? *

If so, please provide that name

First

Last

Date of Birth *

Social Security Number *

Driver's License Number *

State Issued *

DOCUMENT UPLOADS

Resume/CV Upload *

Click or drag files to this area to upload. You can upload up to 4 files.

Allowable File Extensions: .jpg, .jpeg, .png, .pdf, .doc, .docx

Proof of Status *

Click or drag a file to this area to upload.

Resident card, passport, voter's registration

Driver’s License *

Click or drag a file to this area to upload.

PDF Pre-Screening Documents

These documents can be found on the Application Process page and the PDF Screening Page.

Have you completed the (I9) Employment Eligibility Verification (I9) form? *

If you have not completed the I9 form, please finish the application then visit either the Application Process page under CAREERS. We will not be able to process your application until this document is received.

Have you completed the Privacy Policy Acknowledgment form? *

If you have not completed the privacy policy form, please finish the application then visit either the Application Process page under CAREERS. We will not be able to process your application until this document is received.

APPLICANT'S ATTESTATION

I authorize Tri-County Home Care of Florida, Inc. to investigate: *

All information contained herein
All information contained herein except for my current employer.
No, I do not authorize an investigation.

I certify that all information on this application is accurate and complete to the best of my knowledge and I understand that misleading or false statements will constitute sufficient cause for refusal to hire or termination of my employment. *

Yes, I certify.
No, I do not certify.

I understand that, if I accept employment with Tri-County Home Care of Florida, Inc. it will be employment-at-will, which means that either Tri-County Home Care of Florida, Inc. or I have the right to terminate the employment relationship at any time, for any reason, with or without cause or notice. *

Yes, I agree
No, I do not agree.

I acknowledge and understand that the company is an “at will” employer. Therefore, any employee (regular, temporary or other type of category employee) may resign at any time just as Tri-County Home Care of Florida, Inc. may terminate an employee at any time, with or without cause and with or without notice to the other party. *

Yes, I acknowledge
No, I do not acknowledge

I authorize Tri-County Home Care of Florida, Inc. to investigate information concerning my education, employment experiences, and all other aspects of my background relevant to my proposed employment. *

Yes, I authorize
No, I do not authorize

I release Tri-County Home Care of Florida, Inc. and its employees, plus other persons or companies, from all liability arising from such investigation. *

Yes, I agree
No, I do not agree.

I agree to submit to drug and alcohol testing if requested by Tri-County Home Care of Florida, Inc. I release Tri-County Home Care of Florida, Inc. and its employees plus other persons or companies from any and all liability arising out of or related in any way to such testing. *

Yes, I agree
No, I do not agree.

Need Help? Call Us

954.923.0695

Email

info@tricountyhomecare.com

Your application will not be complete until you have accessed the pre-screening documents located either on the Application Process page under Careers or Pre-screening Documents page under Admin/Office page.

PERSONAL INFORMATION

EMERGENCY CONTACT

LEGAL HISTORY

POSITION INFORMATION

PROFESSIONAL & BUSINESS REFERENCES

Personal References

EDUCATION

High School

College or University

Trade School

Employment History

Company #1

Company #2

Company #3

SKILLS & QUALIFICATIONS

PERSONAL VERIFICATION INFORMATION FOR BACKGROUND CHECK

DOCUMENT UPLOADS

PDF Pre-Screening Documents

APPLICANT'S ATTESTATION