Making a postitive impact on their lives and yours.

Elderbee Care LLC is an equal opportunity employer. This application will not be used forlimiting or excluding any applicant from consideration for employment on a basisprohibited by local, state, or federal law. Should an applicant need reasonableaccommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below.

Applicant informationApplicant NameAddressCity, State and Zip CodePhone NumberEmail AddressDate of ApplicationEMPLOYMENT POSITION (Caregiver)How did you hear about this position?What days are you available for work?What hours or shifts are you available for work?On what date can you start working if you are hired?Do you have reliable transportation to and from work?

PERSONAL INFORMATIONHave you ever applied to or worked for Elderbee Care LLC before?

Yes (If yes, please state when below.)

Do you have any friends, relatives, or acquaintances working for ElderbeeCare LLC.?

Yes (If yes, please state name and relationship below.)

Are you 18 years of age or older?

Yes

Are you a U.S. citizen or approved to work in the United States?

Yes

What document can you provide as proof of citizenship or legal status?Will you consent to a mandatory controlled substance test?

Yes

Do you have any condition which would require job accommodations?

Yes (If yes, please describe accommodations required below.)

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

Yes (If yes, please state below. ie. nature of crime, when, where and diposition of the case.)

(Note: No applicant will be denied employment solely on the grounds of conviction of acriminal offense. The date of the offense, the nature of the offense, including any significantdetails that affect the description of the event, and the surrounding circumstances and therelevance of the offense to the position(s) applied for may, however, be considered.)

JOB SKILLS/ QUALIFICATIONSPlease list below the skills and qualifications you possess for the position for which you are applying:

(Note: Elderbee Care LLC complies with the ADA and considers reasonable accommodationmeasures that may be necessary for eligible applicants/employees to perform essential functions. )

EDUCATION & TRAININGHigh School: (Please include - Name of school, Location {City + State}, Year Graduated, Degree Earned)College/University (Please include - Name of school, Location {City + State}, Year Graduated, Degree Earned)Vocational School/ Specialized Training (Please include - Name of school, Location {City + State}, Year Graduated, Degree Earned)Military -Are you a member of the Armed Services?

Yes (If yes, please describe below.)

What branch of the military did you enlist, and how many years did you serve? What was your military rank when discharged?What military skills do you possess that would be an asset for this position?

Previous EmploymentEmployer Name 1:Job TitleSupervisor NameEmployer AddressEmployer TelephoneDates EmployedReason for Leaving

Employer Name 2:Job TitleSupervisor NameEmployer AddressEmployer TelephoneDates EmployedReason for Leaving

Employer Name 3:Job TitleSupervisor NameEmployer AddressEmployer TelephoneDates EmployedReason for Leaving

references

Please provide 3 personal and professional reference(s) below:

Reference 1Reference 2Reference 3

AT-WILL EMPLOYMENT: The relationship between you and the Elderbee Care LLC is referred to as "employmentat 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 Elderbee Care LLC. No representative of Elderbee Care LLC 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 orrepresentations 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.

By checking this box, agree to At-Will Employment, and I authorize Elderbee Care LLC and its authorized agents to verify the information provided in my application, including my employment history, education, and background. I understand that any false or misleading information may result in the rejection of my application or termination of employment."

*Please also email your resume to ciara@elderbeecare.com

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