APPLICATION FOR EMPLOYMENT

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.

PERSONAL INFORMATION

Position Applying For:

CNA (Certified Nursing Assisstant)
LPN (Licensed Practical Nurse)
RN (Registered Nurse)
NP (Nurse Practitioner)
PA (Physician Assistant)
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Name

First Name *

First Name

Last Name *

Last Name

Date *

Date

Address *

Street Address

City *

City

State *

State/Province

Zip Code *

Postal/Zip Code

Home Phone Number *

Please enter a valid phone number.

Social Security Number *

Driver’s License / ID *

State *

Date of Birth *

Email Address *

[email protected]

How did you learn about our company.

Employee Referral
Social Media
Email mail
Other
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Have you ever applied for employment with this Agency? *

Yes

How many hours a week are you available for work? *

8
12
16
20
24
28
32
36
40
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Are you legally eligible for employment in the United States? *

Yes

Are you willing to work:

Day
Evening
Night
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Desired Pay: *

Educational Background*

College / Graduate Information

Name/Location

Major

Years of Study/ Degree

Vo-Tech / Trade Information

Name/Location

Major

Years of Study/ Degree

High School Information

Name/Location

Major

Years of Study/ Degree

Others

Name/Location

Major

Years of Study/ Degree

EMPLOYMENT

List the last five years employment history, starting with the most recent employer.

1. Company Name

Telephone

Address

Dates of Employment

Starting Date

Ending Date

Starting Pay

Ending Pay

Job Title and Describe Work Completed

Reason for leaving

2. Company Name

Telephone

Address

Dates of Employment

Starting Date

Ending Date

Starting Pay

Ending Pay

Job Title and Describe Work Completed

Reason for leaving

3. Company Name

Telephone

Address

Dates of Employment

Starting Date

Ending Date

Starting Pay

Ending Pay

Job Title and Describe Work Completed

Reason for leaving

Was your last name different from your present name during the above listed jobs?

Yes

If yes, what was your name?

Are you currently employed?

Yes

Do you have reliable transportation / the ability to reach multiple clients?

Yes

TWO (2) Professional / Personal Reference Check

1. Reference Full Name *

Phone *

City *

State *

If Professional Reference: Position Held

2. Reference Full Name *

Phone *

City *

State *

If Professional Reference: Position Held

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:

Are you capable of performing the job set forth in the job description?

Yes

If you answered No, which job requirement can you not meet?

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENTOPERATED

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time

Type Signature *

Type Name

Signature *

Clear

Date *