Application Form 
Candidate Picture
* Indicates Mandatory Fields

*First Name
Middle Name
*Last Name
Address 1
Address 2
*Cell Phone
Home Phone
*Email ID
Date of Birth
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Interested Job Category
 Position Applying For
*Preferred County you would like to work
How were you Referred
Available for 24 Hour Care?
Do you have a cell phone with texting capabilities?
Willing to provide service to a client with a pet? Cat  Dog
Willing to provide service to a client who smokes?
Own reliable transportation?
Do you have a valid driver’s license?
DL. No.:  
DL. Expiry Date:
Background Information
Have you ever filed an application with or worked for Familiar Surroundings Home Care?
If yes, provide date:
Do any relatives, including a spouse work for Familiar Surroundings Home Care?
If yes, provide name, relationship and position:
Are you at least 18 years of age?
Do you have proof of your legal right to work in the United States?
Are you currently employed?
Are you willing to travel for work? Check all that apply:
Campbell Milpitas Felton Santa Cruz
Saratoga Santa Clara Scotts Valley Watsonville
Los Gatos Sunnyvale Redwood City Monte Sereno
San Jose Mountain View Brentwood San Carlos
Morgan Hill Los Altos Oakley San Mateo
Gilroy Palo Alto Aptos Boulder Creek
Concord Walnut Creek Bethel Island Antioch
Discovery Bay Richmond
Have you ever been convicted of a misdemeanor or felony(do not include a conviction that has been judicially dismissed or ordered sealed pursuant to law, or a conviction for a minor marijuana offense pursuant to the California Health and Safety Code and which is more than two years old)?
Are you capable of performing, with or without reasonable accommodation, the essential duties of the job for which you are applying?(Make sure you know what the job involves, before answering this question)
Do you have a current TB Test?
Date available for work: What is your desired salary range?
Preferred Day and Time
Day From To
Select All Day
Monday  Apply Time to All
Certificate Name  Expiry Date
Add More Certifications
Hospital Hoyer Lift Incontinent Care Nursing Home
Slide Board Oral Care Private Home Gate Belt
Transfers/ROM Parkinson's Oxygen Excercise
Dementia/ALZ Bed Bath/Bathing Med Reminders Hospice Care
Dressing Pet Care CVA/Stroke Catheter Care
Diabetes Colostomy Care
Name City, State Major / Subject # Yrs Attended Graduate
High School
Previous Employment
Previous Employment 1
Address: City:
State: Zip:
Job Title: From: To:
Supervisor: Phone:
Previous Employment 2
Address: City:
State: Zip:
Job Title: From: To:
Supervisor: Phone:
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Reference 1
Address: City:
State: Zip:
Home Phone: Work Phone:
Relation: Years known:
Reference 2
Address: City:
State: Zip:
Home Phone: Work Phone:
Relation: Years known:
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Applicant's Certification (Please read this carefully before signing the application)
  • FSHC is an equally opportunity employer and will consider applicants for all positions without regard to race, age, color, religion, marital status, nation origin ,disability ,veteran status or any other legally protected status.
  • No applicant will be rejected as a result of any impairment, which, with reasonable accommodation, does not prevent performance of the work.
  • I understand that, if selected, I will be required to provide proof of my identity and legal right to work in the United States prior to actual employment at FSHC.
  • In consideration of my employment. I agree to adhere to all existing and future instructions, rules and policies of FSHC. I also understand that FSHC reserves the right to change wages, hours and working conditions as deemed necessary and that no representative of FSHC has any authority to enter into any agreement for employment for any specified period or to make any agreement contrary to the foregoing.
  • I understand that all employees of FSHC ,with respect to length of employment, are considered to be "at will". This means that I may terminate my employment with FSHC at any time, without notice, without liability, for any extended period. Similarly, FSHC may terminate my employment with at any time without notice,without liability,for any extended period .There is no guaranteed length of employment for any employee. Similarly, any representation by any agent or employee of FSHC to Contrary is not authorized or binding upon FSHC unless in writing and signed by the President of FSHC.
I have read and reviewed the application, my answer , as well as the certification statements above and certify that I have answered truthfully and have not knowingly withheld information relative to my application or resume (if attached).I understand that any misrepresentation or material omission on my application or resume will result in my being eliminated from further consideration. I further understand that,if accepted for employment,any misrepresentation or material omission that becomes known to FSHC may result in immediate termination of my employment.
Applicant Signature: