Please select the branch you are applying to.
East Hartford Branch
1096 Silver Lane
East Hartford, CT 06118
Office (860) 461-1631 / (860) 216-6707
Fax (860) 206-3815
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
Is any additional information relative to change of name necessary to enable Sovereign Home Healthcare, LLC to check references of prior employer?
Has your license ever been suspended or revoked?
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 or more with or without accommodations?
B) Can you assist with patient turning, standing, walking and/or sitting?
Do you have a driver's license?
Do you have automobile insurance?
Please note: Sovereign Home Healthcare, LLC does not provide automobile insurance coverage for your vehicle.
CPR/First Aid Certified?
Do you have certificates or written documentation, if any, for the above?
In which locations will you accept employment? Check the box(es) of all cities/towns you are willing to accept employment?
Please list two professional references.
I hereby authorize Sovereign Home Healthcare, LLC and also authorize 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  hours sleep time Three  hours meal time Three  hours personal time Ten  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 myself to Sovereign Home Healthcare’s 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.
I agree to the terms and conditions above.
I certify that the statements made by me on this application are true and complete the best of my knowledge and are made in good faith. I understand that if I knowingly make any mistake minutes of fact, I am subject to disqualification, dismissal, or other action pursuant to Employment Agency policy and procedure, and subject to criminal penalties as prescribed by law.