Helpmates Incorporated

Application for Employment

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All fields are required.

If applicable

If applicable

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What are the maximum hours you will work per week?

What are the minimum hours you will work per week?

Any employee using an automobile during their course of employment is required to provide proof of current automobile insurance.

If hired, verification will be required consistent with federal law.

If you are over 18, please skip this question.


Name of School No. of Years Attended Degree, Diploma, or Certificate?
High School
Graduate School

Employment History

Start with most recent employer first.

Employer 1

Employer 2

Employer 3

This question does not apply to convictions that have been expunged, sealed, pardoned, or otherwise exhonerated or eradicated. A conviction record will not necessarily be a bar to employment. A conviction which is substantially related to the functions or qualifications of the position(s) for which you are applying may be taken into consideration.

Please describe fully the criminal conviction(s), listing the nature of the offense(s) and your rehabilitation since the conviction(s). If the position for which you are applying falls under specific state law requirements for conducting background checks, then those requirements will also be followed.

Professional References

Please use references that are not related to you and that you have known for at least one year.

Name Address Phone Number

Applicant's Statement

I understand that this application is not a contract, offer or promise of employment. By filling out this application, I am genuinely interested in working for Helpmates, Inc., and I understand that an offer of employment may be subjected to receipt of satisfactory reports and the accuracy of all pre-employment information that I have supplied.

I understand that any employment relationship with this employer is "at will," which means that the employee may resign at any time and Helpmates, Inc. may discharge the employee at any time, with or without cause or advance notice. I understand that this at-will employment relationship may not be changed by any written document or by any behavior. I understand that, if employed, I will be subject to a four (4) month probationary basis. I understand that successful completion of the probationary period does not alter my at will employment relationship.

If employed, I agree to abide by the workplace policies and rules of Helpmates, Inc., consistent with applicable federal, state, and local law. I understand that Helpmates, Inc. has complete discretion to modify its policies, rules, and practices at any time, to the extent allowed by federal or state law, except that it will not modify its policy of employment at-will. By my continued employment with Helpmates, Inc., I consent to any changes.

If employed, I agree to notify Helpmates, Inc. of any changes in my address and/or telephone number.

I certify that the above information is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of information on this application may result in denial of employment, or, if employed, my immediate termination.

I hereby authorize Helpmates, Inc. or its agents to verify all statements contained in this application and/or resume I may submit, to the extent permitted by federal, state, or local law. To the extent permitted by federal, state, or local law, I release all parties from any liability arising out of this provision and the use of such information.

I understand that dependent on the job position and in accordance with applicable state requirements, I will be required to pass a communicable disease test after a conditional offer of employment is made.

I understand that Helpmates, Inc. has a drug and alcohol-free workplace, including a drug and alcohol testing program consistent with applicable federal, state and local law. I acknowledge that if a conditional offer of employment is made to me, I may be asked to submit to a pre-employment (post offer) drug and/or alcohol test. I understand that if a pre-employment (post offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under Helpmates, Inc.’s conditions requiring a drug and alcohol-free workplace. I also understand that, pursuant to federal, state, or local law, all employees may be subject to drug and/or alcohol testing as a condition of continuing employment, and I agree to undergo such testing consistent with the Helpmates, Inc. policy and applicable federal, state, or local law.

Your full name acts as your signature.

Helpmates, Inc. is an Equal Opportunity Employer and does not discriminate on the basis of race, color, creed, sex, age, national origin, ancestry, disability, military status, or any other protected characteristic under federal, state or local law.