Companion Application

Ready to become a companion? Fill out MAH Companion Application and an Advisor will contact you within 24-48 business hours.

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First Name*

Last Name*

Phone Number*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Driver*

Yes

Are you able to provide transportation by driving a client's vehicle?

Transportation*

Yes

Are you able to provide client transportation by using your vehicle? - (mileage reimbursement is included)

Providing client transportation is not a requirement to be hired. However, if you cannot provide client transportation, you will not be matched with clients who include personal transport as part of their service request.

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I would like to receive future email communications from Maxim at Home. Privacy Policy.

Voluntary Self-Disclosure

Maxim at Home is an Equal Opportunity Employer and is subject to certain nondiscrimination and affirmative action recordkeeping and reporting requirements which require the Company to invite employees/applicants to voluntarily self- identify their race/ethnicity, gender and Veteran status. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those which require the information to be summarized and reported to the Federal Government for civil rights enforcement purposes.

Note: Submission of this information is voluntary, that information will be kept confidential, and that refusal to provide information will not subject you to any adverse treatment or be used when considering you for employment with our company. We invite you to answer the following questions.

Please mark the one box that describes the race/ethnicity category with which you primarily identify:*

Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of ethnicity.

White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, North Africa or the Middle East.

Black or African American (Not Hispanic or Latino): A person having origins in any of the black ethnic groups of Africa.

Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A Person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (Not Hispanic or Latino): A person having origins in any of the peoples of the Far East, Southeast Asia, the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

American Indian or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.

I do not wish to answer.

Gender*

Male

Female

I do not wish to answer

Voluntary Self-Identification of “Protected” Veteran Status

The company is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA). VEVRAA requires Government contractors to take affirmative action to employ and advance in employment protected veterans. To help us measure the effectiveness of our outreach and recruitment efforts of veterans, we are asking you to tell us if you are a veteran covered by VEVRAA. Completing this form is completely voluntary, but we hope you fill it out. Any answer you give will be kept private and will not be used against you in any way.

How Do You Know if You Are a Veteran Protected by VEVRAA?

Contrary to the name, VEVRAA does not just cover Vietnam Era veterans. It covers several categories of veterans from World War II, the Korean conflict, the Vietnam era, and the Persian Gulf War which is defined as occurring from August 2, 1990 to the present.

“Protected” veterans include the following categories: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These categories are defined below.

A “disabled veteran” is one of the following:
- a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
- a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

If you believe you belong to any of the categories of protected veterans please indicate by checking the appropriate box below:*

I identify as one or more of the classifications of protected veteran listed below

I am not a protected veteran

I do not wish to answer

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.
Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do I know if I have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

Alcohol or other substance use disorder (not currently using drugs illegally)
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
Blind or low vision
Cancer (past or present)
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or serious difficulty hearing
Diabetes
Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
Epilepsy or other seizure disorder
Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
Intellectual or developmental disability
Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
Missing limbs or partially missing limbs
Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
Partial or complete paralysis (any cause)
Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
Short stature (dwarfism)
Traumatic brain injury

Form CC-305, OMB Control Number 1250-0005, Expires 04/30/2026

Please check one of the boxes below to indicate your disability status:*

Yes, I have a disability, or have had one in the past

No, I do not have a disability and have not had one in the past

I do not want to answer

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

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