Career Application

Employment Application

1096 Silver Lane

East Hartford, CT 06108

• Office (860) 461-1631
• Felix (Director) (203) 809 – 0875
• Georgina (Manager) (860) 502 – 2602
• Fax (860) 206-3815
Info@sovereignhomemakers.com

Career Application - No Pagination

Please select the branch you are applying to. *

1096 Silver Lane East Hartford, CT 06118 Office (860) 461-1631 / (860) 216-6707 Fax (860) 206-3815

1503 Dixwell Avenue Hamden, CT 06514 Office (203) 859-5833 / (475) 655-2483 Fax (475) 441-7891

68 Southfield Avenue, Suite 100 Stamford, CT 06902 Office (203) 921-0370 Fax (203) 921 0369

East Hartford Branch
1096 Silver Lane
East Hartford, CT 06118
Office (860) 461-1631 / (860) 216-6707
Fax (860) 206-3815

Hamden Branch
1503 Dixwell Avenue
Hamden, CT 06514
Office (203) 859-5833 / (475) 655-2483
Fax (475) 441-7891

Stamford Branch
68 Southfield Avenue, Suite 100
Stamford, CT 06902
Office (203) 921-0370
Fax (203) 921 0369

Full Name *

Date of Birth *

Is any additional information relative to change of name necessary to enable Sovereign Homemakers & Companions, LLC to check references of prior employer? *

Yes

If yes, explain *

Current Address

Years Lived *

Street *

City *

State *

Zip *

Previous Addresses

Years Lived *

Street *

City *

State *

Zip *

Add Address Remove

Previous Address 1

Years Lived *

Street *

City *

State *

Zip *

Previous Address 2

Years Lived

Street

City

State

Zip

Home Phone *

Alternative Phone *

In case of emergency, please notify... *

Emergency Contact Number *

What position are you applying for?

Driver's Licence Number *

State Issued *

Expiration Date *

Has your license ever been suspended or revoked? *

Yes

If yes, explain. *

As part of your job description listing, the position you are applying for involves lifting, turning or moving of patients. Please answer the following.

Will you accept assignments which require lifting, turning or moving of patients? If NO, you will not be denied employment for this reason. *

Yes

If YES, A) Can you lift a patient or medical equipment weighing 50lbs or more with or without accommodations? *

Yes

B) Can you assist with patient turning, standing, walking and/or sitting? *

Yes

Do you have a driver's license? *

Yes

Do you have automobile insurance? *

Yes

What type of transportation do you intend to utilize to get to your assignments? *

Please note: Sovereign Homemakers & Companions, LLC does not provide automobile insurance coverage for your vehicle.

School

Type of School *

School Name *

School Address *

Years You Attended *

Graduated? *

Yes

Course or Major *

Add a School Remove

School History 1

Type of School *

School Name *

School Address *

Years You Attended *

Graduated? *

Yes

Course or Major *

School History 2

Type of School *

School Name *

School Address *

Years You Attended *

Graduated? *

Yes

Course or Major *

School History 3

Type of School *

School Name *

School Address *

Years You Attended *

Graduated? *

Yes

Course or Major *

CPR/First Aid Certified? *

Yes

Source of CPR/First Aid Training *

Any additional qualification, education, including medication courses *

Do you have certificates or written documentation, if any, for the above? *

Yes

Prior Work History

Company Name *

Job Title *

Salary *

Address *

State *

Phone *

Nature of Work *

Supervisor *

Reason for Leaving *

From *

To *

May we contact the employer listed above? *

Yes

If not, indicate below which one[s] you do not wish us to contact and why. *

Add Job Remove Job

Work History 1

Company Name *

Job Title *

Salary *

Address *

State *

Phone *

Nature of Work *

Supervisor *

Reason for Leaving *

From *

To *

May we contact the employer listed above? *

Yes

If not, indicate below which one[s] you do not wish us to contact and why. *

Work History 2

Company Name *

Job Title *

Salary *

Address *

State *

Phone *

Nature of Work *

Supervisor *

Reason for Leaving *

From *

To *

May we contact the employer listed above? *

Yes

If not, indicate below which one[s] you do not wish us to contact and why. *

Work History 3

Company Name *

Job Title *

Salary *

Address *

State *

Phone *

Nature of Work *

Supervisor *

Reason for Leaving *

From *

To *

May we contact the employer listed above? *

Yes

If not, indicate below which one[s] you do not wish us to contact and why. *

Please list two professional references.

Reference 1 *

Phone *

Address

Reference 2 *

Phone *

Address

Your E-mail *

Upload your resume.

Maximum file size: 10MB

I hereby authorize Sovereign Homemakers & Companions, LLC and also authorize and request employees and each person given as reference to answer all questions that may be asked, and give all information that may be sought in connection with this application or concerning me or my work habits, character, skills, or my action in any transaction. I further authorize Sovereign Homemakers & Companions, LLC to forward my complete personnel file to any other Sovereign Homemakers & Companions, LLC office at which I may seek future employment.

I further authorize Sovereign Homemakers & Companions, LLC to provide all information concerning me to any individual or organization to which I may be assigned. I understand that if I am applying for or accept a Live-in assignment, it could include ”Live-In” assignments during which I will reside at the client’s premises for more than one consecutive 24-hour period, and I will not be on duty for the entire duration of such assignment. Some Live-In assignments are exempt from coverage under wage and hour laws. If not exempt,

I understand that, unless advised by Sovereign Homemakers & Companions, LLC, prior to or during and assignment, the work schedule for Live-In assignments provides for: Eight [8] hours sleep time Three [3] hours meal time Three [3] hours personal time Ten [10] hours on-duty or on-call I agree to notify Sovereign Homemakers & Companions, LLC whenever the circumstances of the case require otherwise. I agree to report to the office at the end of each assignment, if I am no longer available for work, or if my availability status has changed. I further understand that I cannot be paid until I present a time sheet signed by both the client and myself to Sovereign Homemakers & Companions' office. I certify that the information herein is complete and true and that any material omission, or misrepresentation, shall be sufficient cause for dismissal. I certify that I have fully read and understand the job description provided to me with this application and if accepted for employment, will abide by the terms thereof.

I agree to the terms and conditions above. *

I agree to the terms and conditions above

I certify that the statements made by me on this application are true and complete the best of my knowledge and are made in good faith. I understand that if I knowingly make any mistake minutes of fact, I am subject to disqualification, dismissal, or other action pursuant to Employment Agency policy and procedure, and subject to criminal penalties as prescribed by law.

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Office Hours

Mon: 9:00 am-5:00 pm
Tues: 9:00 am-5:00 pm

Wed: 9:00 am-5:00 pm
Thurs: 9:00 am-5:00 pm
Fri: 9:00 am-5:00 pm
Sat: Closed
Sun: Closed

REACH US

Contact Info
Felix (Director) (203) 809 – 0875
Georgina (Manager) (860) 502 – 2602
Info@sovereignhomehealthcare.com

Reg# HCA0000578

1096 Silver Lane
East Hartford, CT 06118
Office (860) 461-1631
Office (860) 216-6707
Fax (860) 206-3815

Sovereign Home Healthcare

East Hartford Branch
1096 Silver Lane
East Hartford, CT 06118

View on Google Maps

1503 Dixwell Avenue
Hamden, CT 06514
Office (203) 859-5833
Office (475) 655-2483
Fax (475) 441-7891

Sovereign Home Healthcare

Hamden Branch
1503 Dixwell Ave
Hamden, CT 06514

View on Google Maps

68 Southfield Avenue
Suite 100
Stamford, CT 06902
Office (203) 921-0370
Fax (203) 921-0369

Sovereign Home Healthcare

Stamford Branch
68 Southfield Avenue, Suite 100
Stamford, CT 06902

View on Google Maps