Application Form

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Todays Date*

Please enter your full name:*

First Last

Current Address*

Street Address Address Line 2 City State ZIP Code

Time at this address?

Home Phone*

Cell Phone

Email Address*

Date of Birth*

Country of Birth*

Are you eligible to work in the United States?*

Yes

Do you have a valid drivers license?*

Yes

How many miles are you willing to travel for a job?*

Do you have any allergies? -cats, dogs, dust. etc. List each allergy

Have you ever been charged or convicted of a crime or a felony?*

Yes

Have you ever been finger printed?

Yes

Do you have home care experience working with the elderly?

Yes

Available Employment Date:*

Days and Hours You Are Available to Work

Example: Monday: 9AM - 5PM

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Education and Training

(Name and School Location)

High School :

Did you receive a diploma?

Yes

Vocational or Technical School:

Did you recieve a diploma?

Yes

College:

Did you recieve a diploma?

Yes

Are you Certified or Registered in any of the Following?

PCA

CNA

HHA

LPN

Other Skills:

Please Check the Activities That You are Willing to Perform

Bathing - Grooming

Assist in Walking

Cooking

Light Housekeeping

Laundry

Lifting Patient

Running Errands

Work Limitations:

Latest Employer:

Street Address Address Line 2 City State ZIP Code

Contact Person:

First Last

Type of Business:

Your Position:

Date Employed From:

Date Employed To:

Salary:

Reason for Leaving:

Type of Employement:

If this is your current employer, may we contact this employer:

Yes

Second Employer:

Street Address Address Line 2 City State ZIP Code

Contact Person:

First Last

Type of Business:

Your Position:

Date Employed From:

Date Employed To:

Salary:

Reason for leaving

Type of Employement:

If this is your current employer, may we contact this employer:

Yes

Personal References List at Least 2 References - Preferably Work Related

Personal Reference 1:

Street Address Address Line 2 City State ZIP Code

Phone Number we can contact them at:

Personal Reference 2:

Street Address Address Line 2 City State ZIP Code

Phone Number we can contact them at:

Background Information

Our online employment application collects confidential information as part of the hiring process. Nannys for Grannys (the agency) will procure a consumer report and/or investigative consumer report on you in connection with your employment application. The report may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: credit reports, social security number verification, criminal records checks, public court records checks, driving records checks, educational records checks, verification of employment positions held, personal and professional references checks, and licensing and certification checks. The information contained in the report will be obtained from private and/or public record sources, including sources identified by you in your job application or through interviews or correspondence with your past or present co-workers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances. Provided to you with this authorization is a summary of your rights under the "Fair Credit Reporting Act" in a form prescribed by the Federal Trade Commission. Please do not electronically sign the authorization until you have reviewed this summary. You also are entitled to request more information about the nature and scope of the report we are requesting your authorization to obtain by contacting us at the phone number listed at the top of this form. I have carefully read and understand this notice and recognize that this application is also an authorization form and I have read and understand the “ Summary of Your Rights under the Fair Credit Reporting Act”. By my electronic signature below, I consent to the release of consumer and/or investigative consumer reports to the agency as described above and consistent with the requirements imposed on the agency as described in the Summary. I understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed to the agency by me before, during or after my employment, if any, may be utilized for the purpose of obtaining such consumer reports and/or investigative consumer reports about me. I understand that if the client hires me, they may request a consumer report and/or an investigative consumer report about me, to the extent allowed by law, for employment related purposes during and after my employment. I understand that if employed by the client my consent will apply throughout the entire time I am employed by the client unless I revoke or cancel my consent by sending a signed letter to Nannys for Grannys.

Please Read and Check All of the Boxes Below Before Submitting Your Application.

I acknowledge and agree that, if hired, during any employment with Nannys for Grannys, and following termination or expiration of any such employment for any reason, I will not directly or indirectly (i) use for my personal benefit or disclose to any person or entity, confidential information and/or trade secrets of Nannys for Grannys, without the prior written consent of Nannys for Grannys; or (ii) solicit or make an offer to any Nannys for Grannys personnel (whether an employee, independent contractor, or otherwise) to be employed or otherwise perform services outside of Nannys for Grannys.*

Yes, I agree.

I acknowledge and agree that the business in which Nannys for Grannys is engaged is intensely competitive and that, if hired, as a result of employment with Nannys for Grannys I would have access to, and knowledge of, confidential information of Nannys for Grannys including, but not limited to, client lists, client data, personnel information, contracts, forms, and other information and/or trade secrets, all of which are of vital importance to the viability of Nannys for Grannys business. Disclosure (including, but not limited to, partial disclosure) of any of the foregoing would cause Nannys for Grannys to be at a serious competitive disadvantage. If hired, I would have access to, and develop relationships with, clients at the time and expense of Nannys for Grannys.*

Yes, I agree.

I further agree that, for a period of two years following termination or expiration of any employment with Nannys for Grannys for any reason, absent Nannys for Grannys prior written consent, I will not render services of any kind or nature whatsoever to, or solicit, any person or entity which was a client of Nannys for Grannys for whom I rendered services during employment with Nannys for Grannys. Without any way limiting the foregoing, for the avoidance of doubt, this paragraph’s proscriptions include, but are not limited to, rendering services to such client (i) as an employee, independent contractor, or otherwise of such client; or (ii) as an employee, independent contractor, or otherwise of any other person or entity.*

Yes, I agree.

I further agree that upon breaching any of the terms stated in any of the above paragraphs I will pay liquidated damages in the amount of $10,000.00 (ten thousand dollars) per breach to Nannys for Grannys within one (1) month of the date of such breach(es).*

Yes, I agree.

This restrictive covenant agreement (including, but not limited to, agreement to pay liquidated damages for breach thereof) shall inure to the benefit of and be binding upon Nannys for Grannys and any successor organization which shall succeed it (whether by acquisition, merger, consolidation, operation of law, acquisition of assets, or otherwise).*

Yes, I agree.

This restrictive covenant agreement (including, but not limited to, agreement to pay liquidated damages for breach thereof) and any disputes arising out of or relating to it (whether alleged to be in contract, tort, or otherwise) shall be governed by, and construed in accordance with, the laws of the State of New York, without regard to its conflict of law rules, and I consent to the exclusive jurisdiction and venue of the courts of the State of New York, County of New York, for the resolution of any such disputes.*

Yes, I agree.

I agree that the foregoing paragraphs impose a reasonable restraint on me in light of the activities and business of Nannys for Grannys, are enforceable, and protect the legitimate business interests of Nannys for Grannys. The foregoing paragraphs shall be enforced to the fullest extent permissible under the laws and public policies of the State of New York. If any particular portion of the foregoing paragraphs shall be adjudicated to be invalid or unenforceable, they shall be deemed amended to (i) reform the particular portion to provide for such maximum restrictions as will be valid and enforceable, or if that is not possible (ii) delete therefrom only the portion adjudicated to be invalid or unenforceable.*

Yes, I agree.

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract, between me and the client. I understand that any fraudulent statement or material in my application can be grounds for termination of the interview process or of employment with a client regardless of when discovered. If employment with a client begins before a background check is complete, it is conditioned upon a background report that is satisfactory to Nannys for Grannys In addition, I understand and agree that if I am employed by a client, my employment with a client is for no definite or determinable period and may be terminated any time, with or without prior notice, at the option of either myself or the client and that no promises or representations contrary to the foregoing are binding on the agency unless made in writing and signed by me and the agency's designated representative.*

Yes, I agree.

I hereby authorize Nannys for Grannys, at any time prior to or during my employment, to: a) investigate my references b) communicate with my former employers c) conduct an independent investigation of my character, conduct and employment record, including without limitation, a criminal background check.*

Yes, I agree.

Pursuant to title 10, Section 400.23 of the New York Cod of Rules and Regulations, the home care agency is required to conduct a drug test and criminal background check of all applicants for employment in non-licensed positions providing direct patient care and or supervision. Pursant to these regulations, we are required to notify you in writing. (1.) We will submit your fingerprints to the New York State Dept. of Health and request the Dept. forward such information to the Attorney General of the United States. The Attorney General will then conduct a full search of records of the Federal Bureau of Investigation to ascertain if you have any record of a criminal conviction. (2.) The Attorney General will provide its findings to the New York State Dept. of Health which in turn will forward the results to us. If the background check reveals that you have been convicted of certain enumerated crimes, your application for emplyment will be rejected. If you have been offered provisional employment, such employment will be terminated. (3.) Pursuant to the regulations, you have the right to: (a.) Obtain a copy of the of the drug test results, criminal background check, review the information contained and explain the same. (b.) Withdaw your application for employment without prejudice at any time before we make a decision on your application. In such event we will destroy your fingerprint card and any information we may have obtained in connection with the drug test and criminal background check. (c.) The finger-printing, drug test and criminal background checks are conducted at no cost to you. (d.) Any information we receive about you as a result of a drug test and criminal background check will be used only for determining your suitabliity for employment in a position involving direct patient care or supervision. Such information will be treated as confidential and will not be disclosed to anyone else except as permitted by law. (e.) If your employment application is denied because of the information obtained during the course of a drug test and criminal background check, we will provide you with a written statement of our decision and the basis thereof.*

Yes, I agree.

I hereby certify that answers given herein are true and complete to the best of my knowledge.*

Yes, I agree.

Please enter your full name below to confirm your acknowledgement that you have read the above. By entering your name below it constitutes an electronic signature sustainable by law.*

First Last

Application Form

Days and Hours You Are Available to Work

Education and Training

Personal References List at Least 2 References - Preferably Work Related

Background Information

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