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PRE- APPLICATION QUESTIONNAIRE
THIS IS AN APPLICATION AND MUST BE TREATED AS SUCH.

*Required Fields

Applicant Information

Name*
Email*
Phone*
Cell

What is the best way to contact you? Phone Cell Email

Desired Job Position

Do you have a valid:

Social Security Number	Yes No
California ID/DL	Yes No
Credentials	Yes No
Tin Number	Yes No
Work Permit	Yes No

Please answer the following questions.

If hired, Can you give written evidence of the legal right to work in the United States?	Yes No
What areas are you willing to work?
Desired Rate?
Do you have reliable transportation?	Yes No
Can you arrive to your assigned job on time, everyday?	Yes No
Can we verify previous employment?	Yes No
Are you willing to release background information including criminal background?	Yes No
Are you willing to take a drug screen according to our policy?	Yes No
Do you have any distinctive mark/s on your body?	Yes No
Have you lived in another state?	Yes No
If so, Where? When

Attach your resume: (optional)

* I AGREE, by checking this box and submitting this application, I state that all information given by me on the following application is true to the best of my knowledge. I authorize Ancestral Home Health Care Providers Inc. to verify such information and to contact any reference given by me.