Apply to Join Advanced Senior Support

Thank you for your interest in joining our team. This application is for candidates who are ready to submit a full employment form after reviewing our Careers and Job Requirements pages. Completing the application may take a few minutes, and we appreciate the time you take to share your experience with us.

Pro Tip: You can save time by having your license details and work history ready before you begin.

Please complete all required fields so we can best understand your experience and interests.

Advanced Senior Support

Home Health & Mobile Therapy

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, age, disability, veteran status, or any other protected status.

Personal Information

First name

Last name

Birthday

Month

Day

Year

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Additional Information

Have you lived in Ohio for the last 5 years?

Yes

If no, please list additional state(s) you lived in:

I am a U.S. citizen or otherwise authorized to work in the United States on an unrestricted basis

Yes

If applicable, please list visa type, number, and expiration:

Have you worked or attended school under any other name? (This includes maiden name if applicable)

Yes

If yes, provide additional name(s):

The following 2 questions apply to any felony or misdemenor. This includes crimes that have been expunged IF there is a direct and substantial correlation to the job you are applying for:

Have you ever been convicted of, or pleaded guilty to a felony?

Yes

Have you ever been convicted of, or pleaded guilty to a misdemeanor?

Yes

If "yes" to either of the questions above, please provide dates and details:

Please note: Answering "yes" to either of the 2 questions above does not constitute an automatic rejection for employment. Date of these offenses, seriousness and nature of the violation, rehabilitation, and position applying for will all be considered.

Upload Resume (Optional)

Position Information

Position you are applying for:

Date available to start:

Month

Day

Year

Registry or License Number (if applicable):

Are you seeking:

Full-Time

Part-Time

Other

Education & Training

High School Name:

Years Attended (From-To):

Address

Did you graduate?

Yes

If no, did you receive your GED?

Yes

Special Honors or Awards:

College Name:

Years Attended (From-To):

Address

Degree (if applicable):

Major (if applicable):

Did you graduate?

Yes

Special Honors, Awards, or Certifications:

Any other skills, additional training, or certifications held that are related to the position for which you are applying:

References

Please list two references other than previous employers

Name

Professional

Personal

Name

Professional

Personal

Employment History

Company name

Name and Title of Supervisor:

Phone

Dates of Employment (From-To):

Reason for leaving:

Job Title & Duties:

Company Name:

Name and Title of Supervisor:

Phone

Dates of Employment (From-To):

Reason for leaving:

Job Title & Duties:

May we contact all Employers listed above?

Yes

If no, indicate which one(s) you do not want us to contact:

Consent and Agreement:

Please read each paragraph carefully. By checking each box, you are agreeing to the statements written.

I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that omission, concealment, or misrepresentation of any fact on this application, or during an interview for employment, may cause for my immediate dismissal.

I give Advanced Senior Support permission to use any information given on this application to enable it and its agents to verify the information contained in this application. I authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other person(s) to answer all questions asked by Advanced Senior Support.

Advanced Senior Support may conduct a criminal background investigation, and I understand that my employment with Advanced Senior Support may be contingent upon the results of such investigation.

I release Advanced Senior Support, its agents, and all affiliated entities, as well as any person or institution that provides Advanced Senior Support with any information about me, from any and all liability whatsoever resulting from investigation or disclosure of such information.

In consideration of my employment and of my being considered for employment by Advanced Senior Support, I agree to abide by all company rules and regulations, which I understand are subject to change at any time - for any reason - without prior notice. I also understand that if I am employed, I will be an employee at will and employed for no definite period of time. I understand that either the company or I may terminate my employment at any time - with or without cause or advanced notice.

I agree, in consideration of your employing me, that I will not seek or accept employment, either directly or indirectly in any capacity from any client of Advanced Senior Support to whom I have been assigned, for at least six (6) months after the last day of the assignment. I also agree that I will not solicit these clients on my behalf nor on behalf of any future employers.

Applicant's Name (printed):

Applicant's Signature

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Date

Month

Day

Year

Consent for Background Investigation

I authorize release of background check information and fingerprint information to Advanced Senior Support. I understand to be in-compliance with state and federal laws that my employment will be based not only on my skills and qualifications, but on the outcome of my background check, fingerprint status, and Senate Bill 160.

Applicant's Signature:

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Date

Month

Day

Year

Social Security Number

Date of Birth

Month

Day

Year