Application for Employment Access Home Care - Dayton   Telephone 937-224-9991 Our policy is to provide equal employment opportunity to all qualified persons without regard to race, creed, color, religious belief, sex, sexual orientation, age, national origin, ancestry, physical or mental disability, or veteran status. Part 1 - Personal information   * Required Fields * First Name Middle Initial * Last Name Street Address City State Zip * Telephone Email Address DO YOU HAVE A DRIVER'S LICENSE? Yes No DO YOU HAVE PROOF OF AUTO INSURANCE? Yes No N/A Do you have reliable transportation to and from work? Driver's license number State(s) of issue Expiration date Have you had any accidents during the past three years? How many? Have you had any moving violations during the past three years? How many? Position applied for How did you hear of this opening? Please select one Terrionna Swain   If other, please enter here > When can you start? Desired Wage $ If hired, can you present evidence of your identity and legal right to work in the country in which you applied? Yes No Are you looking for full-time employment? Yes No If no, what hours are you available? Are you willing to work different shifts in the same week? Yes No Are you willing to work nightshift? Yes No