Application for Employment - Amicable Home Health Care

Personal Information

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Home Phone*

Business Phone

Email*

Emergency Contact

person not living with you

Have you ever applied for employment with this Agency?

Yes
No

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes
No

How did you learn of our organization?

Newspaper Ad
Agency Employee
Other

Are you willing to work:

Evenings
Weekends

Position applying for:

LVN
RN
Therapist

Therapist (Specify)*

Education Information

Check all that apply

College
Vo-Tech or Trade School
High School
Other

College Name

Location

Course of Study

Years of Degree/Study

Diploma

Vo-Tech or Trade School Name

Location

Course of Study

Years of Degree/Study

Diploma

High School

Location

Course of Study

Years of Degree/Study

Diploma

Other

Location

Course of Study

Years of Degree/Study

Diploma

Previous Employment Information

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

Company 1 – Name

Company 1 – Address

Street Address City State ZIP Code

Company 1 – Phone

Company 1 – Date of Employment

Company 1– Job Title and Describe your work

Company 1 – Starting Pay

Company 1 – Reason for leaving

Company 2 – Name

Company 2 – Address

Street Address City State ZIP Code

Company 2 – Phone

Company 2 – Date of Employment

Company 2 – Job Title and Describe your work

Company 2 – Starting Pay

Company 2 – Reason for leaving

Company 3 – Name

Company 3 – Address

Street Address City State ZIP Code

Company 3 – Phone

Company 3 – Date of Employment

Company 3 – Job Title and Describe your work

Company 3 – Starting Pay

Company 3 – Reason for leaving

Company 4 – Name

Company 4 – Address

Street Address City State ZIP Code

Company 4 – Phone

Company 4 – Date of Employment

Company 4 – Job Title and Describe your work

Company 4 – Starting Pay

Company 4 – Reason for leaving

Company 5 – Name

Company 5 – Address

Street Address City State ZIP Code

Company 5 – Phone

Company 5 – Date of Employment

Company 5 – Job Title and Describe your work

Company 5 – Starting Pay

Company 5 – Reason for leaving

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

Yes
No

If Yes, what was your name?

Are you currently employed?

Yes
No

Do you have reliable transportation?

Yes
No

Professional References

Persons who can furnish information about job performance

1. Name

Telephone

Address

2. Name

Telephone

Address

3. Name

Telephone

Address

General Information

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

Conviction will not necessarily disqualify an applicant from employment.

Yes
No

If yes, describe in full*

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

Yes
No

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

Credentials/Specialized Skills & Qualifications/Equipment Operated

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

Terms of Agreement

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

Please check box below*

I agree to the terms described above