1. Employment Application
Employee Name: ____________________________________ Social Security Number: _____________________ Date: _________________
Physical Address: ________________________________________________________________________________________________________
Street Address City State Zip
Mailing Address (if different from above): ________________________________________________________________________________________
Phone: _______________________ Cell: ________________________ Email: ______________________________________________________
Education/Training:
High School/GED: ___ Yes ___ No _________________________________________________________ Graduation Date: __________
Vocational/Training School: ________________________________________________________________ Graduation Date: __________
College: ________________________________________________________________________________ Graduation Date: __________
Certifications: ___________________________________________________________________________________________________________
Relevant Skills: _________________________________________________________________________________________________________
Language Fluency: _______________________________________________________________________________________________________
Prior Healthcare Experience (Volunteer, Education, and/orProfessional): ____Yes ____ No
Most Recent Experience: _________________ ______________________________________________________________________________
Dates Place of Business/Address
________________________________________________________________________________________________________________________
Duties
Past Experience: __________________ ____________________________________________________________________________________
Dates Place of Business/Address
________________________________________________________________________________________________________________________
Duties

2. Work Experience:
Resume Attached: ___ Yes ___ No
Last/Current Employer Dates Job Title Pay Rate
Address City State Zip Reason for leaving
Supervisor/Title Phone Email
Job Description
Previous Employer Dates Job Title Pay Rate
Address City State Zip Reason for leaving
Supervisor/Title Phone Email
Job Description
Previous Employer Dates Job Title Pay Rate
Address City State Zip Reason for leaving
Supervisor/Title Phone Email
Job Description

3. Employment Eligibility:
Are you authorized to work in the USA? ___ Yes ___ No
Are you at least 18 years old? ___ Yes ___ No
Driving Record:
Do you have a current state issued Driver’s License? ___ Yes ___ No
Driver’s License #: _______________________ State: ______________ Expiration Date: _________________
Have you been convicted of a DUI in the last 7 years? ___ Yes ___ No
Year: _____________ County/State: ______________________ Has your license been reinstated? ___ Yes ___ No
Past Driving Offenses (Please list in the spaces below any driving infractions on your record in the last 7 years. Use the back of the application if
additional space is needed.)
Year County State Driving Infraction Points
Do you own a vehicle? (A “No” will not automatically disqualify a candidate from the position.) ___ Yes ___ No
Year: _________ Make/Model: _________________________ Color: ________________ License Plate #: _______________
Background Check:
Have you ever plea bargained or been convicted of a crime (felony or misdemeanor) in the last 10 years? ___ Yes ___ No
A “Yes” does not automatically disqualify you from the position. Please complete the spaces below
Year County State Crime? Jail or Probation

4. Employment References (Please list three references of current or former employers or co-workers.)
Name Relationship Business Name Phone Email
Character References (Please list three references of former educators, neighbors, or family friends that can comment on your character.)
Name Relationship Organization Phone Email Years Known
Employment Restrictions:
Are you a cigarette smoker? ___Yes ___ No
Are you willing to work in an environment that prohibits smoking during all work hours? ___ Yes ___ No
Do you have any physical limitations that would prohibit you from performing any functions of the position? ___ Yes ___ No
(Please note in the space below any limitations.)
Drug Testing Employment Policy:
EGS Home Care Partners is a drug free environment. All employees are prohibited from using all illegal or legal narcotics unless prescribed by a
physician. While Marijuana is legal in the State of Colorado for recreational use, employees are prohibited from using this narcotic during work
hours. If found imbibing in Marijuana or other legal narcotic use (such as Alcohol) the employee may be subject to disciplinary action, up to and
including employment termination.

5. Prescription Usage Employment Policy:
If you are required to take any prescribed narcotic at any time during your employment with EGS Home Care Partners, it is your responsibility to
inform your supervisor immediately to ensure that you are assigned accordingly. This would be considered a physical limitation and may restrict the
types of assignments that you can work on. This is mandated to ensure your and the client’s safety.
Do you understand and agree to abide by the above drug testing and prescription usage employment policies? ___ Yes ___ No
Allergies:
Do you have any allergies towards animals, cleaning materials, or food products that may impact your working with a client? Please note below any
of those items.
Emergency Contact(s):
Name: _______________________________ Relationship: _____________________________ Phone: ____________________
Name: _______________________________ Relationship: _____________________________ Phone: ____________________
Availability:
Notate in the boxes below your work availability. (Please note that the more restrictive the schedule, the more difficult it is for management on
finding a client that meet your expectations. Flexibility is preferred.)
Day Morning Afternoon Overnight
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

6. Are you able to work on call or short notice assignment as needed? ___ Yes ___ No
Are you able to accept short notice assignments at any time throughout the day? ___ Yes ___ No
What time of day preferences do you have to accept short notice assignments? ________________________________________________________
How much notice would you need to get ready in such an event? ___________________________________________________________________
Application Agreement:
I understand that the information provided on this application will be used only for consideration of my employment through EGS, Inc. I
affirm that the statements made on this application, including all statements concerning my former employment and education, are true and complete.
I authorize EGS, Inc. to investigate any statement contained in any part of this application. I understand that any false statement, omission of fact, or
misinterpretation of facts on this application or other forms provided to EGS, Inc. will be grounds for termination.
I hereby authorize EGS, Inc. and each former employer, except as indicated, and any person, firm, corporation, or educational institution
given as a reference to answer all questions that may be asked is a requirement to be considered for employment with EGS, Inc.
I understand that completing this form does not constitute an offer of employment or an employment agreement between me and EGS, Inc.
Applicant Signature: ______________________________________________________________ Date: ______________________