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APPLICATION FOR EMPLOYMENT

Embry Care Services is an Equal Opportunity Employer and is committed to creating and sustaining a workplace that is diverse and equal. Embry Care Services provides equal opportunity to all applicants for employment on the basis of an individual’s qualifications and without regard to an individual’s race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age (40 or older), disability, or genetic information or any other bias prohibited by law. Applicants may request an accommodation to participate in the application process.

You must complete all questions on the application.

APPLICANT INFORMATION

First Name *

Middle Name *

Last Name *

Office Location: *

Position Applied for:

Street Address

City

State/Province

ZIP / Postal Code

Cell Phone *

Phone

Email *

Where are you interested in working? (Please Provide Zip Code)

Do you have a referral? *You could receive up to $2,000 for each referral!

** You could receive up to a $2,000 referral bonus for each referral!

** PLEASE NOTE: You will be required to complete a Federal Criminal History Record

HOW DID YOU HEAR ABOUT US?TVPrint Advertisement/BillboardAgency/OrganizationCurrent/Former AssociateInternet

Education

High School: *

School Address:

Did you graduate?* *YesNo

Degree:

College

College:

College Address:

Did you graduate?yesNo

Degree

Other Education

Other Education:

Address:

Did you graduate?YesNo

Degree:

Other credentials/licenses/professional affiliations, etc., which are relevant to the position, for which you are applying:

REFERENCES

Please list three professional (work related) references.

First Reference - Full Name: *

Relationship: *

Company: *

First Reference - Phone: *

First Reference - Email: *

Second Reference Full Name:* *

Relationship: *

Company: *

Second Reference Phone: *

Second Reference Email: *

Third Reference - Full Name:*

Relationship:

Company:

Third Reference - Phone:

Third Reference - Email:

PREVIOUS EMPLOYMENT

Please begin with your current or most recent employer

Company: *

Phone - Employment:

Street Address

Supervisor:

Job Title: *

From: *

To: *

Reason for leaving: *

May we contact your previous supervisory for a reference? *YesNo

Company:

Phone - Employment:

Street Address

Supervisor:

Job Title:

From:

To:

Reason for leaving:

May we contact your previous supervisory for a reference? *YesNo

MILITARY SERVICE

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

ADDITIONAL INFORMATION

Are you legally authorized to work in the United States? *YesNo

Pursuant to the Immigration Reform and Control Act of 1986, all applicants, upon being made an offer of employment, must produce documents, which are specified by the federal government, establishing their identity and authorization for employment in the United States. These documents must be produced no later than seventy-two hours after commencement of employment. You will also be required to sign Form I-9 verifying under oath, your employment authorization.

Have you ever had a professional license or certification revoked or suspended? *YesNo

Have you been vaccinated against COVID-19? *YES, fully vaccinated (2+ shots of Moderna or Pfizer-BioNTech; or 1+ shot of Johnson & Johnson’s Janssen)YES, partially vaccinated (1 shot of Moderna or Pfizer-BioNTech)No

EMBRY CARE MISSION AND VALUES STATEMENT

Embry Care is dedicated to providing high quality, comprehensive home health and personal care services to our valued patients in our community.

Embry Care is committed to providing client-centered and home health services to our clients to assist them to lead dignified and independent lives in the comfort and safety of their own homes.

As a potential new associate of Embry Care, if accepted for employment, I will adhere to the principles of the Mission and Values Statement. I pledge to do my best to anticipate the needs of all patients, and will ensure that the best patient experience, with all of our patients, every time. I will also commit to act with integrity in all that I do and treating our patients and other staff members with dignity, respect and compassion.

Signature*

First

Last

Date *

DISCLAIMER, CERTIFICATION AND SIGNATURE

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.

I certify that the information contained in this application is true and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination of employment if discovered at a later date. I agree that Embry Care, Inc. shall not be liable if my employment is terminated because of falsity of statements, answers or omissions made by me in this application.
I understand that all offers of employment are contingent upon successful completion of a Pennsylvania Criminal Background Check, an FBI Background Check, PA Department of Public Welfare (DPW) Child Abuse Clearance and reference checks. I absolve Embry Care of any liability in releasing any information regarding past employment. I also waive Embry Care of any liability and waive all rights to see or review comments that are furnished to Embry Care.
I authorize the investigation of any or all statements contained in this employment application. I also authorize whether listed or not, any person, school, current or past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I also release from liability Embry Care and its’ representatives for requesting, receiving and using such information to make employment decisions and all other persons and organizations for providing such information.
I understand I will/may be required to have my physician supply a pre-employment physical examination including the ability to perform the essential functions of the job. I understand that medical screenings may be required as part of my position.
If employed, I agree to inform a Human Resources representative of any reasonable accommodation(s) required to perform the essential functions of my job.
I understand that, if hired, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement, contract or offer for employment. Accordingly, either I or Embry Care can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
I also understand that, if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within 3 days of starting work as required under the Immigration Reform and Control Act. Failure to submit such proof within the required time shall result in a delayed start date and/or immediate termination of employment.
I understand that, if hired, I will abide by all rules, regulations, policies and procedures of Embry Care. I also agree to immediately update Embry Care should my contact information (e.g. name, address, phone number, etc.) change as this is required for payroll, benefits, job-related and other purposes.

I have read, fully understand the foregoing and seek employment under these conditions.

Signature*

First

Last

Date *

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Home
About
Resources
Locations
Pennsylvania
New Jersey

Pennsylvania Services

Office of Developmental Programs

Consolidated Waiver

PFDS Waiver

Community Living Waiver

Office of Long Term Living

Community HealthChoices Waiver

New Jersey Services

NJ Division of Developmental Disabilities

Supports Program

Community Care
Contact

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