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Applicant Information
Name (First, Middle, Last)
*
Have you worked under any other names?
*
Yes
No
If yes, please list the other name(s)
*
Position(s) Applying For:
*
Certified Nursing Assistant
Home Health Aide
Home Health Aide / Personal Care Assistant
Homemaker
Nursing Supervisor
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
*
Email
Social Security Number
Driver's License number
Expiration Date
MM
DD
YYYY
Do you have your own reliable transportation?
*
Yes
No
If no, please explain:
Do you speak any languages other than English?
*
Yes
No
If yes, please list the first language other than english below:
*
Please check all that apply (first language other than english):
Speak
Read
Write
Do you speak any additional languages other than english?
*
Yes
No
If yes, please list the second language other than english below:
*
Please check all that apply (second language other than english):
Speak
Read
Write
Are there any other languages that you speak other than english?
*
Yes
No
If yes, please list the third language other than english below:
*
Please check all that apply (third language other than english):
*
Speak
Read
Write
Upload your resume
Employment Information
Are you seeking Full-time, Part-time or Per diem work?
*
Select
Full-time
Part-time
Open to full or part-time
Per diem
What days and hours are you available to work?
*
Salary Requirements
Date Available For Work
*
Please indicate the earliest date you will be available for work.
How did you hear about this position?
*
Select
Our website
Friend
Health Care Worker
Classified Ad
Job Fair
Internet Search
Newspaper
TV
Magazine
CareerBuilder.com
Monster.com
Other
Other:
Emergency Contact Information
Name
First
Last
Phone
Relationship to you?
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Education
High School
Please enter the name of your high school
City and State
Years attended?
Did you graduate?
Yes
No
Name of the degree/diploma or certificate awarded?
Vocational Training School
Please indicate the name of the vocational school you attended
City and State
Years attended?
Did you graduate?
Yes
No
Name of the degree/certification or diploma awarded
College
Please indicate the name of the college you attended
City and State
Years attended?
Did you graduate?
Yes
No
Name of the degree/certification or diploma awarded
Do you have CPR certification?
*
Yes
No
CPR Certification Expiration Date
MM
DD
YYYY
Nursing or CNA License Number (if applicable)
License Expiration Date
MM
DD
YYYY
Employment History
Indicate below all current and past employers. Please account for any gaps or periods of unemployment.
Current or Most Recent Employer (Employer #1)
Position/Job Title
Start Date
End Date
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
May we contact this employer?
Yes
No
Phone
What was your salary or hourly pay?
Reason for leaving?
Name of Supervisor
Supervisor's phone number
Brief description of your job duties/responsibilities.
Explain any gap in employment between Employer #1 and Employer #2.
Employer #2 Name
Position/Job Title
Start Date
End Date
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
May we contact this employer?
Yes
No
Phone
What was your salary or hourly pay?
Reason for leaving?
Name of Supervisor
Supervisor's phone number
Brief description of your job duties/responsibilities.
Explain any gap in employment between Employer #2 and Employer #3.
Employer #3 Name
Position/Job Title
Start Date
End Date
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
May we contact this employer?
Yes
No
Phone
What was your salary or hourly pay?
Reason for leaving?
Name of Supervisor
Supervisor's phone number
Brief description of your job duties/responsibilities.
Explain any gap in employment between Employer #3 and Employer #4.
Employer #4 Name
Position/Job Title
Start Date
End Date
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
May we contact this employer?
Yes
No
Phone
What was your salary or hourly pay?
Reason for leaving?
Name of Supervisor
Supervisor's phone number
Brief description of your job duties/responsibilities.
Explain any gap in employment between Employer #4 and Employer #5.
Employer #5 Name
Position/Job Title
Start Date
End Date
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
May we contact this employer?
Yes
No
Phone
What was your salary or hourly pay?
Reason for leaving?
Name of Supervisor
Supervisor's phone number
Brief description of your job duties/responsibilities.
Professional References
Please list three individuals below, who have knowledge of your work performance during the last five years.
Do you give your permission for our agency to contact the individual references listed below? (Please type "Yes" or "No")
Name (Reference 1)
Title
Phone
How does this individual know of your work performance?
How long has this individual known you?
Name (Reference 2)
Title
Phone
How does this individual know of your work performance?
How long has this individual known you?
Name (Reference 3)
Title
Phone
How does this individual know of your work performance?
How long has this individual known you?
Eligibility and Background Questions
Non-Discrimination
Our agency prohibits discrimination against and harassment of any employee or any applicant for employment because of race, color, national or ethnic origin, age, religion, disability, sex, sexual orientation, gender identity and expression, veteran status or any other characteristic protected under applicable federal, state or local laws.
Are you legally eligible for employment in the United States?
*
Yes
No
If hired, can you provide proof of your legal right to work in the US?
*
Yes
No
Do you have a current fingerprint clearance card?
*
Yes
No
Have you ever had a fingerprint clearance card?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please provide specifics, including dates, plea, verdict or finding of guilt, location and current status:
*
Do you have any other responsibilities that will interfere with the duties of the job for which you are applying?
*
Yes
No
If yes, please explain:
*
Do you have any friends or relatives employed by this company?
*
Yes
No
If yes, please list their name(s) and relationship to you:
*
Have you ever worked for a home care or home health agency?
*
Yes
No
If yes, please indicate the name of the company and your position:
*
If hired, there may be clients that cannot be left unattended until your scheduled relief has arrived. Will you have the flexibility to stay when necessary until relief arrives?
*
Yes
No
If no, please explain:
*
If hired, can you work weekends and holidays as needed?
*
Yes
No
If no, please explain:
*
Can you be available for shifts offered on short notice?
*
Yes
No
Acknowledgements
I hereby certify that the foregoing answers are true and complete to the best of my knowledge. I understand that any misrepresentation, falsification or omission of facts on this application or other forms that I may submit in connection with my application for employment, will be sufficient cause not to hire or cause to terminate my employment whenever discovered. I authorize the authorities of Home Is [Company] (the “Agency”) to investigate references and all other statements made on this application and authorize any entity or individual to provide information related to this application including but not limited to: employment records, including attendance records, work performance, disciplinary reports, letters of reprimand, involuntary termination information and other disciplinary action, without giving me notice of such disclosure. I authorize the Agency to make inquiries of courts and law enforcement agencies for records of prior convictions. I acknowledge that I am not obligated to disclose sealed or expunged records of convictions or arrests, and I understand that the Agency will not consider such information in making any employment decision. I agree to cooperate fully with the Agency's background checking process, including, but not limited to executing any additional consent forms necessary to conduct background checks or drug testing. If a conditional job offer is extended, I hereby give permission to conduct a pre-employment screening, which may include background checks, drug screening and a complete physical examination. I expressly agree not to hold the Agency liable in any manner in connection with the investigations and inquiries described above. I understand that if I become employed I will abide by all Agency rules and policies. I also understand that employment with the Agency is "employment at will" and that my employment and compensation may be terminated, with or without cause, with or without notice, at any time at the option of the Agency or myself. This application is not a contract or guarantee of employment.
Testing Authorization
If offered a position with the Agency, I hereby agree to any legally permitted physical, psychological, competency, skill, drug, or medical test required by the Agency as a condition of employment.
Investigation Authorization
I authorize initial and post-hire investigations into all statements and references contained in this application. Said investigation may include: OIG Exclusion List Verification, Aide Certification Verification, Vehicle Insurance Verification, Fingerprint Clearance Card Verification, Credit, Driving, Criminal background, reference checks, and other background checks.
Work Hazards
I understand that if I accept employment with the Agency, I may be exposed to potential hazards related to the provision of homecare services within private residences or medical facilities. Such hazards include but are not limited to physical exertion related to heavy lifting, continuous motion, standing for long periods of time, and exposure to on the job chemicals such as cleaning agents and medications.
Agreement
By typing my initials and my complete name below, I acknowledge that I have read and understood the policies and conditions contained herein and agree to be bound by them if employed by [Company]
Please type your initials:
*
Please type your full name:
*
Today's Date:
*
MM
DD
YYYY
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