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Contact Us (203) 414-5919

Shelton, CT

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APPLICATION FOR EMPLOYMENT

Hubcare Service is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application
process, he or she should contact a company representative.

APPLICANT INFORMATION

First name

Last name

Phone

Email

Position(s) applying for

Have you received the COVID-19 vaccinations? * Required

Yes

No

Address

How many years of experience do you have?

Date of birth * required

EMPLOYMENT POSITION

How did you hear about this position?

What type of license do you have? * Required

Personal Care Assistant (PCA)

Certified Nursing Assistant (CAN)

Licensed Practical Nurse (LPN)

Registered Nurse (RN)

None

On what date would you be available to start? * required

What days are you available to work? * Required

Mon

Tue

Wed

Thu

Fri

Sat

Sun

What shift are you available to work? * Required

AM

PM

If needed, are you available to work overtime? * Required

Yes

No

Do you have a reliable source of transportation? * Required

Yes

No

Desired salary

PERSONAL INFORMATION

Have you ever applied to or worked for Hubcare Service before? * Required

Yes

No

If you have applied before tell us when

Do you have any friends, relatives, or acquaintances working for Hubcare Service? * Required

Yes

No

If you have any friends, relatives, and acquaintances state their name & relationship

Are you 18 years of age or older? * Required

Yes

No

Do you have any condition which would require job accommodations? * Required

Yes

No

If you have any condition please describe accommodations required below.

Are you a U.S. citizen or approved to work in the United States? Proof of citizenship or immigration status will be required upon employment. * Required

Yes

No

Have you ever been convicted of a criminal offense (felony or misdemeanor)? * Required

Yes

No

If you have been convicted please state the nature of the crimes, when and where convicted and disposition of case

JOB SKILLS/QUALIFICATIONS

Please list below the skills and qualifications you possess for the position for which you are applying

(Note: Hubcare Service complies with the ADA and considers reasonable accommodation
measures that may be necessary for eligible applicants/employees to perform essential
functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical
examination conducted by a medical professional.)

EDUCATION AND TRAINING

High School

Name*

Location (City, State)*

Year Graduated*

* required

Degree Earned*

College/University

Name

Location (City, State)

Year Graduated

Degree Earned

Vocational School/Specialized Training

Name

Location (City, State)

Year Graduated

Degree Earned

ADDITIONAL INFORMATION

Indicate any foreign languages you can speak, read or write

Do you hold any other state license or certificate? * Required

Yes

No

Indicate computer skills

If you have other state licenses or certificates (Please add license or certificate number and expiration date)

EMPLOYMENT EXPERIENCE

Beginning with your PRESENT OR MOST RECENT employment or volunteer experience and working
backward, list all positions held which are necessary for determining your eligibility for employment. List
all positions (titles) separately, even if with the same employer. Clearly describe the work (duties) you
personally performed. You must fill out this application completely even if a resume is being attached.

Employer name

Job Title

Supervisor name

Employer Telephone

Employer address

Employed from * required

End date * required

Job description

Reason for leaving

EMPLOYMENT EXPERIENCE #2

Employer name

Job title

Supervisor name

Employer telephone

Employer address

Employed from

End date

Job description

Reason for leaving

EMPLOYMENT EXPERIENCE #3

Employer name

Job title

Supervisor name

Employer telephone:

Employer address:

Employed from

End date

Job description

Reason for leaving

MILITARY EXPERIENCE

Are you a member of the Armed Services? * Required

Yes

No

What branch of the military did you enlist?

How many years did you serve in the military?

What was your military rank when discharged?

What military skills do you possess that would be an asset for this position?

REFERENCES
Please provide 3 personal and professional references below

Reference #1

Name*

Phone Number*

Location (City, State)*

Relationship*

Reference #2

Name*

Phone Number*

Location (City, State)*

Relationship*

Reference #3

Name*

Phone Number*

Location (City, State)*

Relationship*

APPLICANT STATEMENT

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 may be prescribed by law or personnel regulations. All statements made on this application, including employment information, are subject to verification as a condition of employment.This application for employment shall be considered active for a period not exceeding 60 days. Any applicant wishing to be considered for employment beyond this period should inquire as to whether or not application are being accepted at that time.

Your Signature

Signature Date * required

Upload your resume (Optional)

Select File

AT WILL EMPLOYMENT

The relationship between you and the Hubcare Service is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Hubcare Service. No representative of Hubcare Service has authority to enter into any agreement contrary to the foregoing"employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Your Signature

Signature Date * required

Thank you for submitting your application.

5 Commerce Dr. Suite #4

Shelton, CT 06484

HubCare Services
Non-Medical Homecare
Nursing Temporary Staffing Agency
Transportation Service

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