Connecticut Companion and Home Care Services 2490 Black Rock Turnpike Suite 320 Fairfield, CT 06825

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1 To protect your personal information, please do not send the application via . The application and the authorization for release of information must be signed. Please mail the signed application to the following mailing address: Connecticut Companion and Home Care Services 2490 Black Rock Turnpike Suite 320 Fairfield, CT Upon receipt of the Application and the signed Authorization for Release of Information, you will be called to set up a convenient time for an interview.

2 Connecticut Companion and Home Care Services LLC Application for Employment Date Phone # Alternate Phone # Social Security Number Circle the position(s) for which you are applying: Companion CNA HHA LPN Office Other Are you interested in any of the following? Circle all that applies: Live-In Overnight Come and Go List days and hours you can work: Address Your name as it appears on your Social Security Card Last First Middle Your current address Street City State Zip How Long? Previous address (required if you have been at your present address for less than 7 years) Street City State Zip How Long? Driver s License Number State Class of License (For driving jobs only YOU must be 21 years of age to be considered for a driving position) Professional Licenses/Certificates (Required for all CNA, HHA,LPN applicants) Type License # State Expiration Date Type License # State Expiration Date Have you served in the U.S. Military? Yes No Branch Dates Education High School / GED Circle one) Name/City/State of School #of Years Did you Graduate? Degree Vocational / Tech College / University

3 List any special skills or qualifications you possess that would benefit this position. EMPLOYMENT HISTORY: This section must be complete for your application to be considered. The correct telephone numbers of past employers and references are critical. Most recent employer 2 nd most recent employer 3 rd most recent employer Please list dates and details regarding any periods of unemployment REFERENCES: Give two references, not relatives or former employers

4 How did you hear about Connecticut Companion and Home Care Services? Circle Employee Referral Employee s Name Newspaper Ad Van/Car Sign Walk-In Web Other Have you ever been convicted of a law violation? Yes No Exclude any minor traffic violations Include any pleas of guilty or no Contest Circle answer No Yes If yes, give details: (A misdemeanor conviction will not necessarily disqualify an applicant for employment.) Have you ever been convicted of a crime involving violence or dishonesty in a State Court or Federal court in any State? No Yes (If yes, list the crime and the State in which it was committed) Are you over 18 years of age? Yes No (If hired, you may be required to provide proof of age) If hired, can you furnish proof you are eligible to work in the United States? Yes No Do you have a reliable vehicle? Yes No I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatement of fact, I am subject to disqualification and dismissal and to such other penalties as maybe prescribed by law or employment agency policy and procedure. Signature of Applicant Date I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditioned upon successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE. Signature of Applicant Date

5 AUTHORIZATION FOR RELEASE OF INFORMATION The State of Connecticut requires a comprehensive background check of all homemaker-companion agency employees. I hereby authorize Connecticut Companion and Home Care Services LLC and/or affiliates, officers, employees, agents, or representatives to conduct a thorough investigation of my background, and, in furtherance of this investigation to contact all previous employers, educational institutions and persons named in my application for employment, as well as government agencies, law enforcement agencies, licensing boards, and any other persons who may have information concerning my background, employment, character, and qualifications. I release Connecticut Companion and Home Care Services LLC and/or affiliates, officers, employees, agents, and representatives, and all persons (whether corporate or natural) contacted in connection with this investigation, from any and all liability for damages of whatever kind, which may at any time result to me, because of any requests for or the provision of any information in connection with the investigation. I understand that all of the information provided below is true, correct, complete, and without omissions of any kind. I understand and agree that if at any time it is discovered that any information that I provided below, or in my application for employment, is false, misleading, or incomplete, Connecticut Companion and Home Care Services LLC may, in its sole discretion and without liability to Connecticut Companion and Home Care Services LLC, immediately terminate my employment. Name Date of Birth Last First M.I. Previous Maiden/Nick Names Circle: Male Female Height: Eye Color Hair Color Weight Social Security Number Telephone Current Address City State Zip Place of Birth (State or Country if not U.S.) List Counties and State where you have worked and/or resided in the past seven (7) years: Have you ever had an administrative finding of abuse, Neglect, or Theft? Circle: Yes No If Yes, give full details and State. Continue on back if more space is needed. Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated delinquent? Circle: Yes No If Yes, give full details of each offense and the State in which convicted. Continue on back if more space is needed. Applicant s Signature: Date Verification of the following will be performed: Criminal History Reference Check Education Social Security Residence Address Previous Employment Driving History