U.S. Care Systems, Inc.

Specializing in Professional Home Care Services since 1985

2614 Genesee St., Utica, NY 13501 (315) 793-0090 uscare@uscaresystems.com

Employment

U.S. Care Systems, Inc. Online Employment Application

Personal Information

Name:

Street Address:

City:

State:

Zip:

Phone No:

( )

Email:

Position:

How did you learn about U.S. Care Systems?

If you were referred to us by one of our employees? Please list his/her name here:

Have you ever applied for a position with us? Yes No

If "yes," when and for what position?

Have you ever been employed by us? Yes No

If "yes," when and in what program?

Some positions involve working evening and weekend hours, can you fill such scheduling requirements? Yes No Not Applicable

Do you desire: Full time? Part time?

Availability

We offer employment opportunities in the counties listed below. Please select those counties you are willing to serve.

Delaware Herkimer Jefferson Lewis Madison Oneida Otsego

How many hours per week are you able to work?

Please state hours that you are available: to

What days are you available to work:

Mon Tues Wed Thurs Fri Sat Sun

For information purposes, choose your primary mode of transportation:

Car Bus Walk

If available to work weekends, how many per month can you commit to?

Are you available to work nights (6pm-7am)? Yes No

A 10% shift differential is paid for working nights. If yes, choose the nights you are able to work:

Mon Tues Wed Thurs Fri Sat Sun

Miscellaneous

Are you over the age of 18? Yes No

Do you have the legal right to live and work in the United States? Yes No

Have you ever been convicted of or plead guilty to a crime? (A conviction will not automatically disqualify you from being considered as a candidate for employment.)
Yes No

If "yes," please explain:

Education

Type of School and Address of School	Major	No. of Years Attended	Graduation
High School G.E.D.
			Graduated? Yes No Date:
Trade of Business School
			Graduated? Yes No Date:
College or University
			Graduated? Yes No Date:
Graduate School
			Graduated? Yes No Date:

Other formal training applicable to work at U.S. Care Systems:

Professional References

Please list three (3) professional references.
Name	Address	Telephone

Employment History

List current or most recent employer first, including U.S. Military Service.

If any employment was under a different name, indicate name:

Employer 1:

Address:

Telephone:

Position Held:

Dates of Employment:

From: To: Full-Time Part-Time

Number of Hours:

Ending Salary $:

Supervisor Name:

Duties:

Reason for Leaving:

Employer 2:

Address:

Telephone:

Position Held:

Dates of Employment:

From: To: Full-Time Part-Time

Number of Hours:

Ending Salary $:

Supervisor Name:

Duties:

Reason for Leaving:

Employer 3:

Address:

Telephone:

Position Held:

Dates of Employment:

From: To: Full-Time Part-Time

Number of Hours:

Ending Salary $:

Supervisor Name:

Duties:

Reason for Leaving:

Employer 4:

Address:

Telephone:

Position Held:

Dates of Employment:

From: To: Full-Time Part-Time

Number of Hours:

Ending Salary $:

Supervisor Name:

Duties:

Reason for Leaving:

May we contact your present employer? Yes No

May we contact your previous employers? Yes No

If you answered "no," indicate which you do not want us to contact and why:

Applicant Acknowledgement

*PLEASE READ CAREFULLY BEFORE SIGNING*

I hereby certify that all of the information provided by me in this application (or any accompanying documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents may be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that if employed, my employment with U.S. Care Systems is at-will and for no specified duration and may be terminated by either U.S. Care Systems or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions or statements of U.S. Care Systems representatives used during the employment process alter the at-will nature of my employment in any way or is deemed a contract of employment, real or implied.

If employment with U.S. Care Systems is obtained under this application, I agree to conform to the rules, regulations, policies and procedures of U.S. Care Systems, which I understand are subject to change from time to time by the Agency, at all times and understand that such compliance is a condition of employment. I understand that due to the nature of U.S. Care Systems business, attendance and punctuality are considered essential requirements of every employee of U.S. Care Systems and that poor attendance or tardiness will result in disciplinary action.

I understand that placement into any position offered is conditioned upon the Agency's receipt of a satisfactory background investigation. The investigation will include verification of employment history and education, and, where appropriate, may also include but not be limited to investigation of criminal record, driving record, status with the State Central Register for the Abuse and Maltreatment of Children and professional references. I understand that any offer of employment is contingent upon my passing a drug test conducted at a site designated by U.S. Care Systems, and that failure to submit to or pass the drug test will rescind the offer of employment in accordance with the Agency's Drug Free Workplace Policy. Additionally, I understand that placement will be conditioned upon satisfactory completion of a job-related physical examination.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to U.S. Care Systems and/or any of its representatives, and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for one year. If I wish to be considered for employment after this period I must fill out and submit a new application.

It is the policy of U.S. Care Systems to hire, place, transfer and promote employees without regard to race, color, sex, national origin, religion, age, veteran status, non-job-related condition, disability, sexual orientation or any other legally protected status.

Print your full name into this box if you acknowledge that you have read, understand and agree with the above statement: