Call Us Today at 1-562-929-8400 for job interview

PRELIMINARY EMPLOYMENT APPLICATION

    We are a job placement / referal agency. A-1 Domestic is always looking to hire experienced
    Caregivers, Companions, Aides, Assistants, CNA, CHHA, Home Attendants, Sitters, Au Pair,
    Babysitters, Homemakers, Mother's Helper & Nannies for non-medical In Home Care and
    Child Care services.

    We are an equal opportunity employer. Equal access to programs, services and employment is
    available to all persons. Those applicants requiring reasonable accommodation to the
    application and / or interview process should notify a our Human Resources Department.

Contact Information:

Name

Nick Name

Address

E-Mail

Home Phone

Cell

Work

May we contact you at work?

Yes No

If yes, best time to reach
you at work:

General Information

If under 18, can you furnish
a work permit?

Yes No

If no, please explain:

Have you submitted an
application previously?

Yes No

If yes, give date(s):

Have you ever been
employed here before?

Yes No

If yes, give date(s):

Are you legally eligible
to work in this country?

Yes No

Date available to work:

Position desired:

Full-Time Part-Time Temporary

Seasonal Educational Co-op

Will you relocate if job
requires it?

Yes No

Will you travel if job
requires it?

Yes No

Driver's license number:

State:

   Are you able to meet the
   attendance requirements
   of the position?

Yes No

Will you work overtime
if required?

Yes No

If no, please explain:

Have you ever been
bonded?

Yes No

Have you been convicted of
a crime in the last 7 years?

Yes No

If yes, please explain:

Conviction will not necessarily be a bar to employment. Each instance and explaination
will be considered in relation to the position for which you are applying.

Employment History

Most Recent Employer

Employer

Telephone

Address

Supervisor and Title

May we call for reference?

Yes No

Your Job Title

  Summarize the type of
  work performed and
  job responsibilities

Dates Employed	Starting Rate / Salary	Final Rate / Salary
From To	$ per	$ per

  Comments
  (including explanation of
  any gaps in employment)

Other Employment

Employer

Telephone

Address

Supervisor and Title

May we call for reference?

Yes No

Your Job Title

  Summarize the type of
  work performed and
  job responsibilities

Dates Employed	Starting Rate / Salary	Final Rate / Salary
From To	$ per	$ per

  Comments
  (including explanation of
  any gaps in employment)

Skills and Qualifications

   Summarize any special
   training,skills, licenses
   and / or certificates that
   may qualify you as being
   able to perform job-
   related finctions in the
   position for which you
   are applying.

Educational Background

   List the last three (3) schools attended, starting with most recent. List number of years
   completed. Indicate degree or diploma earned, if any. List grade point average and class
   rank. As well as major and minor (if applicable) field of study.

School	Years Completed	Degree / Diploma	GPA / Class Rank	Major	Minor

References

   List name and telephone number of three (3) business / work references who are not related
   to you and are not previous supervisors. If not applicable, list three (3) school or personal
   references who are not related to you.

Name of Reference	Telephone Number	Years Known

Additional Information

   List professional, trade, business, or civic associations and any offices held. Exclude
   memberships which would reveal sex, race, religion, national origin, age, color, disability or
   any other similarly protected status.

Organization	Offices Held

   List special awards,
   accomplishments,
   publications, etc.

   List any additional
   information you would
   like us to consider.

Referral Method:

Relative

Employee

Advertisement in:

Employment Agency:

Other:

Note: Policy requires all applicants also fill out an application in person at our corporate headquarters. The information above is an exact copy of what will be asked on our paper application. If you'd like, please print this page for easy reference when called for an interview.

“It Takes Two Helping Hands and a Golden Heart to Serve Others®”