EMPLOYMENT APPLICATION

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time. Please read "Applicant Note" below. Complete all pages pf this application. Print clearly. Incomplete or illegible applications may not be accepted. If more space is needed to complete any question, use comments section on the back. Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with TTC,LLC. This is not an employment contract. Please answer all appropriate questions accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

Today's Date

Date

Position(s) Applied For

Last Name*

First Name*

Middle

Date of Birth*

Date

Social Security Number*

Street*

City*

State*

Zip Code*

Home Phone*

Work Phone

Cell Phone*

Alternate Phone

Emergency Contact Name*

Emergency Contact Phone*

Valid Driver's License #*

Exp. Date*

Date

Make & Model of Vehicle*

Year of vehicle*

Auto In Co*

Policy #*

Exp Date*

Date

Have you ever submitted an application here before? Yes / No If yes, when?

Have you ever been employed here before? Yes / No If yes, when?

How did you hear about Tender Touch Caregivers, LLC?

Have you been given a copy of the job description for the position for which you have applied to review. Yes / No Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? Yes / No

Yes

Why are you interested in employment with us?*

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

What date are you available to begin work?

Date

Please complete all areas of availability:

Mornings

Afternoon

Evenings

Overnights

Weekdays

Weekends

Please indicate the days of the week as well as the earliest and latest times that you are available for work. Tuesday MondayWednesdayFridaySaturday Sunday Shift From:

PREFERENCES

Please indicate the days of the week as well as the earliest and latest times that you are available for work. Tuesday MondayWednesdayFridaySaturday Sunday Shift From:

Please indicate all areas of the city in which you are willing to work

Please indicate the types of services which you are willing to provide: Companionship Meal PreparationLaundry/Ironing Activities (games/crafts)Medication Reminders *In order to be able to provide transportation or run errands, you will be required to have a valid driver's license and current auto insurance.Amotor vehicle record check will be conducted and proof of insurance will be required.

Housekeeping (dust/vacuum)

Laundry/Ironing

Medication Reminders

Are you willing to provide service to a client with a pet? Yes / No If yes, which ones:

No

Cats*

Dogs*

Are you willing to provide service to a client that smokes? Yes / No

Describe any training or life skills you have that apply to caring for a senior*

Describe any work history you have that would apply to caring for a senior*

What do you like (or think you would like) most about working with older adults?*

What do you like (or think you would like) least about working with older adults?*

What personal rewards do you get from working with seniors?*

Please circle highest grade completed:

Grade School

High School

College

*For employment our minimum education requirement is either a GED or High School diploma

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Are you currently working for this employer? Yes / No

If yes, may we contact? Yes / No

Yes

Company Name

City

State

Phone Number

Dates Employed: From

Date

Job Title

Supervisor's Name

Duties

Salary

(Hour, Week, Month)

Reason for Leaving

Company Name

City

State

Phone Number

Dates Employed: From

Date

Job Title

Supervisor's Name

Duties

Salary

(Hour, Week, Month)

Reason for Leaving

Company Name

City

State

Phone Number

Dates Employed: From

Date

to

Job Title

Supervisor's Name

Duties

Salary

(Hour, Week, Month)

Reason for Leaving

Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.

As a condition of employment all employees must be "Bondable"8 "Insurable". Are you at least 18 years of age? Yes / No

List states and counties of residence for the past seven years:

Have you had any moving traffic violations? Yes / No If yes, please describe:

If yes, please describe

Have you been charged/convicted of a felony and/or misdemeanor/or served time Yes / No If yes, please describe: IncidentCity/State Charge 1)

1)

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? Yes or No.

REFERENCES (Do not include relatives) Please complete all five references. Your application will not be considered unless 5 references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 5 references, you will be asked to provide additional references. (STAFF ONLY- References checked*No or *Yes check one) Phone NumberNumber of Full Name Best Time of Relationship Years Known Day to Call

List all 5 References. Name, number and relationship*

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verifyanyofthis information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools,companiesandlaw enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which mightresultfrom making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. background My employment is contingent upon confirmation of credentials and successful completion of drug test or criminalcheck.I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship with the agency andmyselfis terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Anychanges inthisemployment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

APPLICANT SIGNATURE

DATE*

Date

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

EDUCATION

WORK HISTORY

SECOND MOST RECENT EMPLOYER