Employment Inquiry Form

In-Home Care Provider

Contact Information
18 years or older?
Desired Employment
Sun Mon Tue Wed Thu Fri Sat

Related Experience

Do you have any experience working with Seniors or individuals with Developmental Disabilities? If so, please check all that apply:


Previous or Current Employer #1

Previous or Current Employer #2
Languages Spoken

Do you speak any other languages?

Resume (optional)

I understand and agree that nothing contained in this employment inquiry or in granting an interview, creates an employment contract between Pacific Homecare Services and me for either employment or for the providing of any benefits. No promises regarding employment have been made to me. If I am offered employment, I understand it is conditional upon a clear criminal background check and that employment can be terminable "at will", and I have a right to terminate my employment at any time and that Pacific Homecare Services also retains a similar right to terminate my employment at any time.

I understand that should I become employed by Pacific Homecare Services, my work assignments, schedules, and work locations are subject to change according to the needs of the business and the clients of the agency.

Pacific Homecare Services is an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.