* = Required Information

DATE: April 03, 2026

Name Last * First * Middle Maiden

Present address Number Street City State Zip

How long at this address? Social Security No.

Telephone Cell phone

If under 21, please list age

Do you now, or have you lived outside the state of Indiana in the last 2 years?

Position applied for (1) and salary desired (2)

Days/hours available to work

No Pref Thur Mon      Fri     Tue       Sat   Wed     Sun   All Days     Hrs

How many hours can you work weekly?

Can you work nights/weekends?

Employment desired      FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME

When available for work? Email Address

TYPE OF SCHOOL NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YEARS COMPLETED MAJOR & DEGREE High School College Bus. or Trade School Professional School

HAVE YOU EVER BEEN CONVICTED OF A CRIME?    YesNo

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

DO YOU HAVE A DRIVER'S LICENSE?    YesNo

What is your means of transportation to work?

Driver's license number State of issue

Type of License Operator Commercial (CDL) Chauffeur

Expiration date

Have you had any accidents during the past three years?                Yes No

How many?

Have you had any moving violations during the past three years?    Yes No

How many?

EMERGENCY INFORMATION

Color, make, & model of car you will be driving most to work.

License plate number

Emergency contact:     Phone:

Emergency contact:     Phone:

Please list two references other than relatives or previous employers.

Name        Name

Position    Position

Company Company

Address      Address

Day-time telephone Day-time telephone

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

What cities are you available to work in? Check all that apply Brookville Versailles Cross Plains Batesville Rising Sun

Are you willing to start with one client and build your clientele?YesNo

Do you have past homemaking experience?YesNo

Have you ever performed attendant care services (personal care, bathing, etc)?YesNo

If not, would you be willing to learn how to perform these services?YesNo

***ALL PROSPECTIVE EMPLOYEES MUST PASS A DRUG SCREEN BEFORE HIRING****

MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES?YesNo

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?YesNo

Specialty Date Entered Discharge Date

Work Experience Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name.

Name of employer Address City State Zip Code Name of last supervisor Employment dates Pay or salary From To Start Final Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer Address City State Zip Code Name of last supervisor Employment dates Pay or salary From To Start Final Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer Address City State Zip Code Name of last supervisor Employment dates Pay or salary From To Start Final Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer Address City State Zip Code Name of last supervisor Employment dates Pay or salary From To Start Final Your last job title Reason for leaving (be specific) List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer?YesNo

Did you complete this application yourself?    Yes No

If not, who did?

Security Code *