FOR EMPLOYEE USE ONLY

OFFER OF EMPLOYMENT ARE CONDITIONED UPON RECEIPT OF THE FOLLOWING:

  1.    COPY OF CERTIFICATE/LICENSE
  2.    JOB DESCRIPTION -  SIGNED AND DATED
  3.    TWO FAVORABLE REFERENCE LETTERS
  4.    SIGNED BASIC EMPLOYEE POLICIES AND PROCEDURES
  5.    WITHHOLDING TAX FORMS [W-4] IF REQUIRED BY FEDERAL OR STATE LAW
  6.    REQUIRED SKILL TESTING [ANSWER SHEETS]
  7.    I-9 DOCUMENTS

FOLLOW UP DATA:

CPR expiration date

Recertification dates

AFTER HIRE ONLY

[These are to be completed after a “conditioned offer” or employment is made]

  1.    COPY OF VALID DRIVER’S LICENSE
  2.    COPY OF CPR CERTIFICATION
  3.    DOCUMENTATION OF IN-SERVICE/CONTINUING EDUCATION OR SPECIAL TRAINING
  4.    PROOF OF VALID AUTOMOBILE  INSURANCE
  5.    DATE OF LAST TB [PPD] TEST AND/OR OTHER IF REQUIRED BY LAW

DATE OF CHEST X-RAY

DATE OF LAST PHYSICAL EXAM IF REQUIRED BY FEDERAL OR STATE LAW

NAME

ADDRESS

CITY

STATE

ZIP

EQUAL EMPLOYMENT OPPORTUNITY POLICY:

It is the policy and practice of Sovereign Home HealthCare, LLC to abide by all anti-discrimination laws provided by the federal, state, and local statutes and regulations. It is also the policy and practice of Sovereign Home HealthCare, LLC to provide and promote equal opportunities for all applicants and employees. It is also the policy and practice of Sovereign Home HealthCare, LLC to hire, train, promote, compensate, and adminis- ter all employment practices without regard to race, color, religion, sex, national origin, age, marital status, medical condition, veteran status, sexual orientation or disability unrelated to the ability to perform the essential functions of a job. Furthermore, Sovereign Home HealthCare, LLC is com- mitted to complying with the American With Disabilities Act. If you believe that you need a reasonable accommodation in order to apply for or to complete an application for employment due to the fact that you have a disability, please notify Sovereign Home HealthCare, LLC within three [3] days of your application of your specific needs for a reasonable accommodation so that Sovereign Home HealthCare, LLC can assist you where appropriate. If an applicant requests an accommodation for

completing the job application process, Sovereign Home HealthCare, LLC reserves the right to require the applicant to furnish documentation from an appropriate professional [e.g. a doctor, rehabilitation counselor, etc] confirming that the applicant has a disability or concerning their functional limitations for which a reasonable accommodation is requested.

In order that the application may be properly evaluated, it is essential that all of the following questions be answered carefully and completely. If you need more space for your answers, please attach a separate sheet. Feel free to add any additional information which will help Sovereign Home HealthCare, LLC in placing you where you are best qualified.

SELECT BRANCHPlease select the branch your are applying to

DATE OF BIRTH:

APPLICANT NAME:

Is any additional information relative to change of name necessary to enable Sovereign Home HealthCare, LLC
to check references of prior employer?

If yes, explain

Present Address

CITY

STATE

ZIP

Home Phone:

Alternate Phone:

In emergency, please notify:

Phone:

Certification::

License:

State Issued :

Expiration Date :

Has your license ever been suspended or revoked?

If yes, explain

Do you have the legal right to work in United States?

If hired, on what date will you be available to start work?

Have you ever been convicted of a crime?

If yes, explain

As part of your job description listing, the position you are applying for involves lifting, turning or moving of patients. Please answer the following:

Will you accept assignments which require lifting, turning or moving of patients?

If NO, you will not be denied employment for this reason.

If YES,

A] Can you lift a patient or medical equipment weighing 50lbs with or without accommodations?

B] Can you assist with patient turning, standing, walking and/or sitting?

Do you have a Driver license?

Automobile insurance?

What type of transportation do you intend to utilize to get to your assignments?

EDUCATIONAL BACKGROUND

Education Name & Address Years Attend Graduated Course / Major
High School
Vocational/Technical
College/University
Post Graduate

CPR/First Aid certified?

Date

Source of Training

Any additional qualification, education, including medication courses

Do you have certificates or written documentation, if any, for the above?

PRIOR WORK HISTORY[List in order of current employer first]         

Name

Phone

Street Address

State

Zip

Job Title

Salary

From

To

Nature of Work

Supervisor

Reason for Leaving

Name

Phone

Street Address

State

Zip

Job Title

Salary

From

To

Nature of Work

Supervisor

Reason for Leaving

Name

Phone

Street Address

State

Zip

Job Title

Salary

From

To

Nature of Work

Supervisor

Reason for Leaving

Name

Phone

Street Address

State

Zip

Job Title

Salary

From

To

Nature of Work

Supervisor

Reason for Leaving

you do not wish us to contact and why

PROFESSIONAL REFERENCESPlease List 2 Professional Refences. Kindly Exclude employers and Relatives        

I hereby authorize Sovereign Home Healthcare, LLC and request employees and each person given as reference to answer all questions that may be asked and give all information that may be sought in connection with this application or concerning me or my work habits, character, skills, or my action in any transaction. I further authorize Sovereign Home Healthcare, LLC to forward my complete personnel file to any other Sovereign Home Healthcare, LLC office at which I may seek future employment. I further authorize Sovereign Home Healthcare, LLC to provide all information concerning me to any individual or organization to which I may be assigned.

I understand that if I am applying for or accept a Live-in assignment, it could include ‰Live-In‰ assignments during which I will reside at the client’s premises for more than one consecutive 24-hour period, and I will not be on duty for the entire duration of such assignment. Some Live-In assignments are exempt from coverage under wage and hour laws. If not exempt, I understand that, unless advised by Sovereign Home Healthcare, LLC, prior to or during and assignment, the work schedule for Live-In assignments provides for:

Eight [8] hours sleep time Three
[3] hours meal time Three
[3] hours personal time
Ten [10] hours on-duty or on-call

I agree to notify Sovereign Home Healthcare, LLC whenever the circumstances of the case require otherwise.
I agree to report to the office at the end of each assignment, if I am no longer available for work, or if my availability status has changed. I further understand that I cannot be paid until I present a time sheet signed by both the client and I to Sovereign Home Healthcare office.
I certify that the information herein is complete and true and that any material omission, or misrepresentation, shall be sufficient cause for dismissal.
I certify that I have fully read and understand the job description provided to me with this application and if accepted for employment, will abide by the terms thereof.

Signature

Date

WE PROVIDE COMPASSIONATE 
AND AFFORDABLE HOMECARE

SOVEREIGN HOME HEALTHCARE PROFESSIONALS

Sovereign Home Healthcare offers caregiver services, providing social interaction while promoting safety, security and independence in the comfort of one's home.

PERSONAL CARE ATTENDANTS 
(CNA OR HHA)

For clients who need significant assistance with managing and maintaining their household, personal care attendants can also assist with personal, non medical needs such as hygiene.

SOVEREIGN HOME HEALTHCARE PROFESSIONALS

These individuals assist and/or instruct an individual in maintaining a comfortable environment when the person is unable to do so alone. Homemakers/Companions assist with daily activities as needed and directed by the individual. 

What Our Clients Say About Us

Reach Us


Felix Effa (Director) (203) 809 - 0875
Georgina Effa (Manager) (860) 502 - 2602
Albert Cobbina (Administrator) (860) 726 - 3424
nursing@sovereignhomehealthcare.com 
Info@sovereignhomehealthcare.com

Branches


1096 Silver Lane
East Hartford, CT 06118 
Office (860) 461-1631 / (860) 216-6707
Fax (860) 206-3815


1227 Burnside Avenue
East Hartford, CT 06108 
Office (860)-726-4620
Fax (860)-726-4619


1503 Dixwell Avenue
Hamden, CT 06514
Office (203) 859-5833 / (475) 655-2483
Fax (475) 441-7891


68 Southfield Avenue, Suite 100 
Stamford, CT 06902
Office (203) 921-0370
Fax (203) 921-0369