Employment Application | Kelly Home Healthcare Inc.

Before You Begin

Please complete the application accurately and provide the information that applies to you. Required supporting documents will be handled through Kelly Connect during the application and onboarding process.

Application / onboarding documentation may include:

Valid driver's license or state-issued identification
Social Security card
Applicable education or qualification documentation
CNA documentation when applying as a CNA
CPR documentation when applicable
Physical and TB documentation when required
Vehicle insurance when transporting participants
Do Not Drive Agreement when the employee will not transport participants
Required pre-employment screenings and onboarding forms

Position & Location

Select the position and Kelly Home Healthcare location for which you are applying.

Position Applying For *

Homemaker Apply for a Homemaker / Home Service Worker position.

CNA Apply for a Certified Nursing Assistant position.

Location *

Applicant Information

Enter your legal name and current contact information.

First Name *

Last Name *

Email Address *

Your Kelly Connect account will use this email address.

Phone Number *

Street Address *

City *

State *

ZIP Code *

Date Available

Desired Pay

Are you legally authorized to work in the United States? *

Yes No

Have you previously worked for Kelly Home Healthcare Inc.? *

Yes No

Previous Position / Approximate Dates

Education & Training

Provide your education and applicable training information.

High School / GED

School Name

City / State

Did you graduate or receive a GED?

Yes No

College / Vocational / Other Training

School / Program

City / State

Degree / Certificate / Qualification

Field of Study

CNA Applicant

Because you selected CNA, please answer the following. Your CNA documentation can be provided through Kelly Connect.

Are you currently a CNA?

Yes No

Do you currently have CPR certification?

Yes No

No CNA registry or certification number is requested on this application.

Emergency Contact

Please provide an emergency contact.

Full Name *

Relationship *

Phone Number *

Alternate Phone Number

Address

Employment History

Please begin with your most recent employer.

Employer 1 — Most Recent

Employer Name

Phone Number

Employer Address

Supervisor

Job Title

Start Date

End Date

Job Duties / Responsibilities

Reason for Leaving

May we contact this employer?

Yes No

Employer 2

Employer Name

Phone Number

Employer Address

Supervisor

Job Title

Start Date

End Date

Job Duties / Responsibilities

Reason for Leaving

May we contact this employer?

Yes No

Employer 3

Employer Name

Phone Number

Employer Address

Supervisor

Job Title

Start Date

End Date

Job Duties / Responsibilities

Reason for Leaving

May we contact this employer?

Yes No

Military Service

Complete the additional information only if it applies to you.

Have you served in the United States Armed Forces?

Yes No

Branch of Service

Rank at Discharge

From

Training / Experience

Professional References

Please provide professional references who may be contacted regarding your work history or qualifications.

Reference 1

Full Name

Professional Relationship

Phone Number

Email Address

Reference 2

Full Name

Professional Relationship

Phone Number

Email Address

Reference 3

Full Name

Professional Relationship

Phone Number

Email Address

Transportation

Please provide information about your transportation availability.

Do you have reliable transportation to and from work? *

Yes No

Do you have a valid driver's license? *

Yes No

Will you transport Kelly Home Healthcare participants in your personal vehicle? *

Yes No

Do you currently have automobile insurance?

Yes No

If you will transport participants, proof of current automobile insurance will be requested securely through Kelly Connect.

Do Not Drive Agreement

If you will not transport participants, the applicable Do Not Drive Agreement will be provided through Kelly Connect during the application or onboarding process.

Additional Employment Information

Please answer the following questions.

Are you at least 18 years of age? *

Yes No

Are you able to perform the essential duties of the position for which you are applying, with or without reasonable accommodation? *

Yes No

Have you ever been discharged or asked to resign from a position? *

Yes No

Please Explain

Applicant Certification

Please review the certification before signing your application.

I certify that the information provided in this employment application is true and complete to the best of my knowledge.

I understand that false, misleading, or materially incomplete information may affect my eligibility for employment or continued employment with Kelly Home Healthcare Inc.

I authorize Kelly Home Healthcare Inc. to contact employers, professional references, educational institutions, and other sources identified in this application for employment-related purposes.

I understand that additional documents, screenings, acknowledgments, and onboarding requirements may be required before employment.

I have read and agree to the applicant certification above and certify that the information I provided is accurate and complete. *

Electronic Signature

Type your full legal name below to electronically sign your employment application.

By typing your full legal name below, you acknowledge that your typed name represents your electronic signature on this employment application.

Full Legal Name *

Signature Preview

Your signature will appear here

Date Signed

Signature Type

Save Your Application

You can save your progress or complete this application and continue to Kelly Connect.

Your application process continues in Kelly Connect.

After completing the Employment Application, Kelly Connect will display the remaining forms, documents, acknowledgments, and onboarding requirements that apply to you.