Application For Employment

Sully Home Care

Serving Essex, MetroWest, Middlesex, Suffolk, Norfolk, Plymouth, Bristol.

29 Memorial Drive,
Avon, MA 02322
508-510-6963

Thank you for your employment interest with Sully Home Care.

If you would like to be contacted for employment opportunities, please complete the form provided below.

Application for Employment - Step 1 of 2

Fields marked with an * are required.

Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

If you are under 18, can you furnish a work permit?

Employment desired

Full Time
Part Time
Contract

Position Applying for:

PCA
HHA
CNA
LPN
RN
Clerical
Other

Please specify

Date you can start

Are you employed now?

May we inquire of your present employer?

Have you ever applied to this agency before?

When:

Days of the week you are available to work

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Are you able to meet the attendance and time requirements of this position?

This position requires that you travel to the agency’s geographic area; the agency does take into consideration distance between employees / clients’ home to minimize commutes when possible. ONLY indicate towns you are NOT willing to travel to.

It is the policy of this agency to conduct background screening on all agency staff that have direct / in direct patient care and /or access to patient records prior to an offer of temporary or permanent employment. Have you ever been convicted of a felony in the past 7 yrs?

Such conviction may be relevant if job related, but does not bar you from employment. Please explain:

Driver’s license number

State

Statement of Employability

By the execution of this document, I acknowledge that I have been informed by Sully Home Care Services Inc. that a criminal history check may be performed on my current name and all past names. Below are all the names I have ever used (i.e. maiden, aliases, nicknames, etc.- Attach list if necessary)

Date of Birth

Social Security #

Name1

First

Middle

Last

Name2

First

Middle

Last

Name3

First

Middle

Last

I understand that I may be employed on a temporary emergency basis pending the result of the criminal history check. I understand that a person convicted of an offense listed below may not be employed in a position, the duties of which involve direct contact with a consumer. I have NOT been convicted of any of the following offenses:

Criminal Homicide
Kidnapping and false imprisonment
Indecency with a child
Sexual/ Aggravated assault
Injury to a child, elderly, or disabled
Abandoning / endangering a child

Aiding Suicide
Agreement to abduct from custody
Sale or purchase of a child
Arson
Robbery / Aggravated Robbery

I have not been convicted of any of the following penal code offenses, which may potentially bar employment:

Assaultive offense
Burglary and criminal trespass / Theft
Weapons
A felony violation of statute intended to control the possession or distribution of an illegal substance
Fraud
Public Lewdness
Indecent Exposure
Public Indecency

Have you ever been Arrested / Convicted of any offense listed? *

Please provide an explanation

Acknowledgment *

I acknowledge that if I am found to have been convicted of any other offenses, they may cause my employment to be terminated. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

In order to process your application we need the following information (check all that applies).

Resume (if possible)
Social Security card
Picture ID for employment verification & background check
Immigration documents (if applicable)
Copy of your training certificate (HHA/ CNA), professional license or nursing credentials
CPR/CPI or other training certifications
Most recent physical and chest x-ray if applicable

File(s) Upload *

Click or drag a file to this area to upload.

Once the background checks are performed and if you are able to move forward we will contact you to schedule a time for an interview, orientation and to complete the additional employment documents.

If you have any questions contact Marilyn Sully at 508-510-6963x4 or by email at msully@sullyhomecare.com.

By submitting this form, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Sully Home Care Services permission to use any information in this application to enable it and its agents to verify the information contained in this application. I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Sully Home Care Services with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment Sully Home Care Services will conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Sully Home Care Services, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Sully Home Care Services. I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Sully Home Care Services or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Sully Home Care Services at any time, can constitute a contract of employment. No representative or agent of Sully Home Care Services has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Sully Home Care Services is not involved in the day-to-day supervision or decision concerning patient care. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Sully Home Care Services against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

Acknowledgement *

I have read the above and fully understand it.

Name