* = Required Information
Personal Information
 
First Name* Address 1*
Last Name* Address 2
Home Phone* City*
Work Phone State
Mobile Phone Zip*
Email*
Section 1 - Personal Information
 
Date of Birth
Social Security Number
Section 2 - General Information
 
How did you learn about ArchAngels Services, LLC?
Date Available For Work?
Do you have a NJ CHHA or any other Professional License? YesNo
License Number(enter NA if you no license)
If you are a CHHA, do you have malpractice insurance? Enter No if not applicable YesNo
If Yes malpractice insurance carrier & policy number
Has your professional license or certification ever been investigated or suspended (enter No if not applicable)? YesNo
Have you ever been named as a defendant in a professional liability action? YesNo
Have you ever applied at ArchAngels Services, LLC? YesNo
If Yes, where?
Have you ever worked for ArchAngels Services,LLC before? YesNo
Do you have a reliable means of transportation? YesNo
How far are you willing to travel for a 4 hour assignment?
How far are you willing to travel for a 6 hour assignment?
How far are you willing to travel for an 8+ hour assignment?
 
Section 3 - Employment Verification
 
Can you submit verification of your legal right to work in the U.S. YesNo
If you are not a U.S. citizen, please indicate VISA type and number.
Section 4 - Education
High School name and location:
Years Attended (From/To)
Additional Education (vocational, college, etc.) YesNo
If yes, please list the name of the school and years attended (From/To)
Section 5 - Current/Most Recent Employment
Current Employer
Address
City
State
Zip Code
Start Date
End Date (if you still work there skip question)
Schedule Worked
Position/Title
Supervisor's Name/Title
Employer's Phone
Pay Rate
May we contact for employment verification? YesNo
Section 6 - Previous Employment History 1
 
Employer/Company Name
Address
City
State
Zip Code
Start Date
End Date (if you still work there skip question)
Schedule Worked
Position/Title
Supervisor's Name/Title
Employer's Phone
Pay Rate
May we contact for employment verification? YesNo
Section 7 - Previous Employment History 2
 
Employer/Company Name
Address
City
State
Zip Code
Start Date
End Date (if you still work there skip question)
Schedule Worked
Position/Title
Supervisor's Name/Title
Employer's Phone
Pay Rate
May we contact for employment verification? YesNo
Section 8 - Professional References 1 (no family members)
 
Name
Relationship
Phone
Section 9 - Professional References 2 (no family members)
 
Name
Relationship
Phone
Section 10 - Emergency Contact Information
 
Name (First & Last)
Address(City & State)
Phone
Relationship

This agreement is between ArchAngels Services, LLC and the applicant in which ArchAngels Services, LLC and applicant agree to the following:

1. I understand that no fees will be collected from me (the applicant) by ArchAngels Services, LLC
2. While I am a caregiver on assignment, I am an employee of ArchAngels Services, LLC and I am not authorized to:
• Render an opinion on behalf of ArchAngels Services, LLC on the client’s financial matters.
• Handle cash, negotiables or other valuables without written permission from ArchAngels Services, LLC or may not, under any circumstances, transport or convey monies, securities or any negotiable instruments (including, but not limited to, delivering bank deposits to bank or other institution.)
3. I understand that registering with ArchAngels Services, LLC is not a guarantee of employment.
4. I will notify ArchAngels Services, LLC LLC of any event that may prevent me from accepting or completing an assignment. If I am unable to complete my assignment, I will give ArchAngels Services, LLC a minimum of one (1) week notice. I understand that if I do not report to an assignment and I do not contact ArchAngels Services, LLC prior to the assignment start time, ArchAngels Services, LLC may assume that I have voluntarily quit and I will no longer be eligible to work through or be represented by ArchAngels Services, LLC
5. ArchAngels Services, LLC may provide me with opportunities and or job interviews in my field of caregiving. ArchAngels Services, LLC shall, at its own expense, spend time and effort researching the job market and contacting potential clients, which efforts may result in resume presentation and or job interviews. In consideration for the services provided above, I agree that I will not directly solicit or seek employment from any individual or any contact associated with or referred by same, with whom ArchAngels Services, LLC presents my resume to and/or arranges an interview with, and/or places me on assignment with, now or at any time during the twelve (12) months following my resume presentation, interview or assignment. I understand if I do solicit and accept employment with any potential clients in which ArchAngels Services, LLC has presented my resume to within twelve (12) months and do accept employment as either a permanent, contract or temporary position, would be a violation and legal action may be taken to collect damages.

Our employees are often placed in positions where they are required to handle information or work with procedures that are proprietary to our clients.

1. I understand the information I come in contact with is confidential and proprietary.
2. I will not at any time during my employment or any time thereafter publish, disclose, or utilize any confidential or proprietary information and material gained while working as an employee with any client.
3. I will protect the integrity of written records by storing and working with them in an appropriate manner, I will not copy any documents or portion of any document without specific instructions to do so.
4. I understand that as an employee of ArchAngels Services, LLC I may be sent on future assignments to clients that may have been previously serviced directly or indirectly by competitors of ArchAngels Services, LLC. I will not disclose details of my work with any client or discuss my salary.

I have read the Terms and Conditions/Non-Compete Agreement and I understand that they are applicable when I am employed by or represented by ArchAngels Services, LLC.

I hereby certify that the answers given by me to all of the questions contained on this application form are true and correct to the best of my knowledge. If employed by ArchAngels Services, LLC, I will comply with all rules and regulations of the company. I agree to submit to a physical and or drug examination if required. I also authorize my former employers to give any information they have regarding me to ArchAngels Services, LLC, whether or not it is on their records. I authorize ArchAngels Services, LLC to conduct any background checks necessary including, but not limited to: Felony and Misdemeanor convictions, previous arrest history, and driving records. I hereby release ArchAngels Services, LLC from all liability for and damage whatsoever for issuing the same. I understand that if any fraudulent information is given on this application, it will be grounds for immediate termination from my position. ArchAngels Services, LLC is an Equal Opportunity Employer. I understand that job positions are placed equally without discrimination because of race, creed, color, religion, sex, national origin, sexual preference, disability, marital status or age.