216-929-7488 salaamhhc@gmail.com

5700 pearl rd suite 203 Parma Ohio 44229

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About Us

At Salam Home Health Care LLC, we enhance quality of life with compassionate, reliable in‑home care. Our mission is to help each person maintain comfort, dignity, and independence while receiving the support they need—right where they feel most at ease: home.

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Application

Salam Home Health Care

5700 Pearl Rd Suite 203 | Phone: 216-929-7488 | Fax: 216-859-5813

Application for Employment

Personal Data

Date Application Completed OFFICE USE ONLY – Date of Interview OFFICE USE ONLY – Date of Hire

Last First Middle

Social Security Number Home Phone Cellular Number

Address City State

Zip Code Length of Residence

Previous Address

Address City State

Zip Code Length of Residence

Job Interests

Position Applying For How were you referred to us?

Date available for work Anticipated Wage

Specialty Areas (check all that apply)

Availability / Work Status

Work Status:

Full Time (32 hours per week average) Part Time (less than 32 hours per week average)

Education Circle the highest level of education completed

College or Undergraduate Education

Name of School Degree Year Graduated

License / Certifications / Examinations

Type of license State of issuance Expiration date License number

Any restrictions or pending actions against license?

CPR Expiration Last physical examination Last TB/Chest X-ray

General Information

Are you legally authorized to work in the USA?

YES NO

If you become an employee of this Agency, you will be required to provide documentation proving your eligibility to work in the USA.

Have you ever been convicted of a felony or a misdemeanor crime?

YES NO

This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.

If yes, state the basis for each conviction and the date of the conviction:

Have you ever been employed by this agency or one of its subsidiaries?

YES NO If yes, give location and dates:

Emergency Contact

Name Phone Relationship

Work History (begin with present or most recent employer)

Employer 1

Company Name (present or most recent employer)

Employment Dates – From To

Company Address City State

Wage Per hour / Annual

Describe your job responsibilities and duties

Supervisor Name Telephone Number

May we contact this employer?

YES NO Reason for leaving?

Employer 2

Company Name

Employment Dates – From To

Company Address City State

Wage Per hour / Annual

Describe your job responsibilities and duties

Supervisor Name Telephone Number

May we contact this employer?

YES NO Reason for leaving?

Employer 3

Company Name

Employment Dates – From To

Company Address City State

Wage Per hour / Annual

Describe your job responsibilities and duties

Supervisor Name Telephone Number

May we contact this employer?

YES NO Reason for leaving?

Employer 4

Company Name

Employment Dates – From To

Company Address City State

Wage Per hour / Annual

Describe your job responsibilities and duties

Supervisor Name Telephone Number

May we contact this employer?

YES NO Reason for leaving?

Applicant Declaration

The information that I have given is true and accurate to the best of my knowledge.

Applicant Signature Date

About Us

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Our Office Location

Application

Salam Home Health Care

Application for Employment

Previous Address

Specialty Areas (check all that apply)

Availability / Work Status

College or Undergraduate Education

Emergency Contact

Employer 1

Employer 2

Employer 3

Employer 4