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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salaamhhc@gmail.com

Our Office Location

5700 pearl rd suite 203 Parma Ohio 44229

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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

Full Time Part Time

Education Highest level of education completed

Name of School

Degree

Year Graduated

Name of School

Degree

Year Graduated

License / Certifications / Examinations

Type of license

State of issuance

Expiration date

License number

Restrictions or pending actions?

CPR Expiration

Last physical exam

Last TB/Chest X-ray

General Information

Are you legally authorized to work in the USA?

YES NO

Have you ever been convicted of a felony or misdemeanor?

YES NO Explain convictions (if any)

Previously employed by this agency?

YES NO If yes, give location and dates:

Emergency Contact

Name

Phone

Relationship

Work History

Employer 1

Company Name

From

To

Address

City

State

Wage Job Duties

Supervisor

Phone

May we contact?

YES NO Reason for leaving

Employer 2

Company Name

From

To

Address

City

State

Wage Job Duties

Supervisor

Phone

May we contact?

YES NO Reason for leaving

Employer 3

Company Name

From

To

Address

City

State

Wage Job Duties

Supervisor

Phone

May we contact?

YES NO Reason for leaving

Employer 4

Company Name

From

To

Address

City

State

Wage Job Duties

Supervisor

Phone

May we contact?

YES NO Reason for leaving

Applicant Declaration

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

Applicant Signature Date