Applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, marital or veteran status, or the presence of non-job-related medical condition or handicap.

Basic Information Form

Full Name*

First

Middle

Last

Email*

Phone Number*

Address*

City/State*

Zip Code*

Social Security Number*

Date of Birth*

If employed, and you are under 18, do you have a work permit?*

YesNo

Have you filed an application here before?*

YesNo

If yes, give the date.*

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status (Proof of citizenship status may be required upon employment)?*

YesNo

On what date would you be available for work?*

What is your work availability?*

Basic Information Form

In this section, start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, gender or national origin.

Employment Experience*

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, gender or national origin.

Employer Name*

Employer Phone Number*

Employment Dates*

From (mm/yy) To (mm/yy)

Employment Location*

Provide full address including city, state, and zip code

Job Title*

Work Performed*

Supervisor

Reason for Leaving*

Educational Background Form

In this section, give an overview of schools you attended, what years you attended them, and any diplomas or degrees you have. Describe courses of study, describe specialized training, apprenticeship, skills, and extra-curricular activities.

Education*

Give an overview of schools you attended, what years you attended them, and any diplomas or degrees you have. Describe courses of study, describe specialized training, apprenticeship, skills, and extra-curricular activities.

Highest level of education completed:*

Elementary SchoolHigh SchoolCollege/UniversityGraduate/Professional

Elementary School Name*

Years completed:*

45678

Do you have a diploma from this school?*

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

High School Name*

Years completed:*

9101112

Do you have a diploma from this school?*

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:*

College/University Name:

Years completed:

1234

Do you have a diploma from this school?

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

Graduate/Professional School Name:

Years completed:

1234

Do you have a diploma from this school?

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

Languages Form

Indicate languages you speak, read and/or write.

Language #1:*

How fluent are you in this language?*

SpeakReadWrite

Check all that apply.

Language #2:

How fluent are you in this language?

SpeakReadWrite

Check all that apply.

Language #3:

How fluent are you in this language?

SpeakReadWrite

Check all that apply.

Reference Form

Send this form to your reference. By filling out this section, you are agreeing to give permission to release information to Horizon Homemaker & Companion concerning your performance and hereby release your organization from all liability.

Reference Name *

First
Last

Reference Relationship to You:*

Reference Full Address*

Include street, city, state, and zipcode.

Reference Phone Number*

Employee Quality of Work:*

ExcellentGoodAverageFairPoor

Employee Knowledge and Skills:*

ExcellentGoodAverageFairPoor

Employee Cooperation:*

ExcellentGoodAverageFairPoor

Employee Attendance:*

ExcellentGoodAverageFairPoor

Employee Punctuality:*

ExcellentGoodAverageFairPoor

Employee Dependability:*

ExcellentGoodAverageFairPoor

Employee Interpersonal Skills:*

ExcellentGoodAverageFairPoor

Employee Judgment:*

ExcellentGoodAverageFairPoor

Criminal Background History

In completing this criminal background history, pursuant to Connecticut General Statutes Section 31-51i, note that: (A)(1) You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a, (2) criminal records subject to erasure pursuant to section 46b-146, 54-76o or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon, and (3) any person whose criminal records have been erased pursuant to section 46b-146, 54-76o or 54-142a shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath; (B) You will not be denied employment solely on the basis that you had a prior arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a or that you had a prior conviction for which you received a provisional pardon or certificate of rehabilitation pursuant to section 54-130a, or a certificate of rehabilitation pursuant to section 54-108f.

Have you ever been arrested?

YesNo

If yes, please provide the date, and circumstances of the arrest

Have you ever been charged with a crime?

YesNo

If yes, please provide the date, and the crime, with which you were charged.

Have you ever been convicted of a crime?

YesNo

If yes, please provide the date, and the crime, with which you were convicted.

Have you ever been convicted of a crime involving violence or dishonesty in a state court or federal court in any state?

YesNo

If yes, please provide the date, and the crime, for which you were convicted.

Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?

YesNo

If yes, please provide the date, and nature, of such disciplinary action.

Basic Information Form

Full Name*

First

Middle

Last

Email*

Phone Number*

Address*

City/State*

Zip Code*

Social Security Number*

Date of Birth*

If employed, and you are under 18, do you have a work permit?*

YesNo

Have you filed an application here before?*

YesNo

If yes, give the date.*

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status (Proof of citizenship status may be required upon employment)?*

YesNo

On what date would you be available for work?*

What is your work availability?*

Previous Employment Form

Employment Experience*

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, gender or national origin.

Employer Name*

Employer Phone Number*

Employment Dates*

From (mm/yy) To (mm/yy)

Employment Location*

Provide full address including city, state, and zip code

Job Title*

Work Performed*

Supervisor

Reason for Leaving*

Educational Background Form

Education*

Highest level of education completed:*

Elementary SchoolHigh SchoolCollege/UniversityGraduate/Professional

Elementary School Name*

Years completed:*

45678

Do you have a diploma from this school?*

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

High School Name*

Years completed:*

9101112

Do you have a diploma from this school?*

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:*

College/University Name:

Years completed:

1234

Do you have a diploma from this school?

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

Graduate/Professional School Name:

Years completed:

1234

Do you have a diploma from this school?

YesNo

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

Languages Form

Indicate languages you speak, read and/or write.

Language #1:*

How fluent are you in this language?*

SpeakReadWrite

Check all that apply.

Language #2:

How fluent are you in this language?

SpeakReadWrite

Check all that apply.

Language #3:

How fluent are you in this language?

SpeakReadWrite

Check all that apply.

Reference Form

Reference Name *

First
Last

Reference Relationship to You:*

Reference Full Address*

Include street, city, state, and zipcode.

Reference Phone Number*

Employee Quality of Work:*

ExcellentGoodAverageFairPoor

Employee Knowledge and Skills:*

ExcellentGoodAverageFairPoor

Employee Cooperation:*

ExcellentGoodAverageFairPoor

Employee Attendance:*

ExcellentGoodAverageFairPoor

Employee Punctuality:*

ExcellentGoodAverageFairPoor

Employee Dependability:*

ExcellentGoodAverageFairPoor

Employee Interpersonal Skills:*

ExcellentGoodAverageFairPoor

Employee Judgment:*

ExcellentGoodAverageFairPoor

Criminal Background History

Have you ever been arrested?

YesNo

If yes, please provide the date, and circumstances of the arrest

Have you ever been charged with a crime?

YesNo

If yes, please provide the date, and the crime, with which you were charged.

Have you ever been convicted of a crime?

YesNo

If yes, please provide the date, and the crime, with which you were convicted.

Have you ever been convicted of a crime involving violence or dishonesty in a state court or federal court in any state?

YesNo

If yes, please provide the date, and the crime, for which you were convicted.

Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?

YesNo

Careers

Basic Information Form

Full Name*

Email*

Phone Number*

Address*

City/State*

Zip Code*

Social Security Number*

Date of Birth*

If employed, and you are under 18, do you have a work permit?*

Have you filed an application here before?*

If yes, give the date.*

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status (Proof of citizenship status may be required upon employment)?*

On what date would you be available for work?*

What is your work availability?*

Basic Information Form

Employment Experience*

Employer Name*

Employer Phone Number*

Employment Dates*

Employment Location*

Job Title*

Work Performed*

Supervisor

Reason for Leaving*

Educational Background Form

Education*

Highest level of education completed:*

Elementary School Name*

Years completed:*

Do you have a diploma from this school?*

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

High School Name*

Years completed:*

Do you have a diploma from this school?*

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:*

College/University Name:

Years completed:

Do you have a diploma from this school?

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

Graduate/Professional School Name:

Years completed:

Do you have a diploma from this school?

Describe courses of study:

Describe specialized training, apprenticeship, skills, and extra-curricular activities:

Languages Form

Language #1:*

How fluent are you in this language?*

Language #2:

How fluent are you in this language?

Language #3:

How fluent are you in this language?

Reference Form

Reference Name *

Reference Relationship to You:*

Reference Full Address*

Reference Phone Number*

Employee Quality of Work:*

Employee Knowledge and Skills:*

Employee Cooperation:*

Employee Attendance:*

Employee Punctuality:*

Employee Dependability:*

Employee Interpersonal Skills:*

Employee Judgment:*

Criminal Background History

Have you ever been arrested?

If yes, please provide the date, and circumstances of the arrest

Have you ever been charged with a crime?

If yes, please provide the date, and the crime, with which you were charged.

Have you ever been convicted of a crime?

If yes, please provide the date, and the crime, with which you were convicted.

Have you ever been convicted of a crime involving violence or dishonesty in a state court or federal court in any state?

If yes, please provide the date, and the crime, for which you were convicted.

Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?

If yes, please provide the date, and nature, of such disciplinary action.