Save Home Health Care Job Application

Page 1 of 3: Save Home Health Care Job Application Form
An EQUAL OPPORTUNITY EMPLOYER. Employees of this organization and applicants for employment shall be given equal opportunity in all aspects of employment without regard to race, color, national origin, ancestry, sex, age, religion or handicap. PERSONAL AND GENERAL INFORMATION
Last Name *
First Name *
Address *
City *
State
Zip *
Email
Home Phone
Phone Number for Message
Emergency Contact Name
Address
Phone Number(s)
Position Applying For
Expected Salary
Were you previously employed at this organization?	Yes No
If yes, state dates of most recent employment:
Have you worked for this organization using another name?	Yes No
If yes, please give name
Have you ever applied here?	Yes No
If yes, when?
Are you presently employed?
If yes, may we contact your employer?	Yes No
Type of work seeking	Full Time Part Time PRN Per Visit
Shift	Day Evening Night Weekend
Are you willing to rotate weekends?	Yes No
Are you related to anyone employed by this organization?	Yes No
If yes, state name and relationship
How were you referred?	Friend Website Newspaper Employee Other
If Other, please list
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?	Yes No
Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?	Yes No
If yes, please give date(s), place and nature of each such conviction
Are you a U.S. citizen?	Yes No
If not, do you have a visa or other document(s) permitting you to work in the U.S.?	Yes No
Are you at least 18 years of age?	Yes No

Page 2 of 3: Save Home Health Care Job Application Form
WORK HISTORY
Previous Company 1
Address, City, State, Zip
Phone Number
Supervisor's Name
From
To
Position
Number of hours/week
Salary (state whether hr/week/salaried)
OK to contact employer?	Yes No
Describe your job title, responsibilities and accomplishments
Reason for leaving
Previous Company 2
Address, City, State, Zip
Phone Number
Supervisor's Name
From
To
Position
Number of hours/week
Salary (state whether hr/week/salaried)
OK to contact employer?	Yes No
Describe your job title, responsibilities and accomplishments
Reason for leaving
Previous Company 3
Address, City, State, Zip
Phone Number
Supervisor's Name
From
To
Position
Number of hours/week
Salary (state whether hr/week/salaried)
OK to contact employer?	Yes No
Describe your job title, responsibilities and accomplishments
Reason for leaving

Page 3 of 3: Save Home Health Care Job Application Form
EDUCATION
Name and Location of High School
Last Year Attended	9 10 11 12
Graduated
Degree
Name and Location of College
Last Year Attended	1 2 3 4
Graduated
Degree
Name and Location of College
Last Year Attended	1 2 3 4
Graduated
Degree
Name and Location of Other School
From
To
Graduated
Degree
List any training, including seminars, workshops, research internships, qualifications that will assist in the evaluation of your application. Also list any aptitudes and skills that you feel are relevant to the type of emp[loyment you are seeking.
List all current licenses and/or areas of certifications
Typing speed (words per minute)
Shorthand Speed (words per minute)
List all equipment (office, trade or laboratory) that you operate proficiently.
PLEASE READ CAREFULLY BEFORE SIGNING I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresent. I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse. I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I wll have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility. I understand if I am an unlicensed person who has direct patient contact, that the agency will perform a criminal history check per state regulation. Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar Placement office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
By clicking this box, I hereby sign this document and agree that I will be bound by the above *	Click to sign
Date