Employment Form

Position(s) applied for

Type of employment desired

Please Specify Days

If currently employed, may we contact your employee?

Rate of pay Expected Per Hour

Is there a specific reason you are applying for employment at this company?

Are you legally eligible for employment in this country?

Are you available to work overtime if required?

Have you applied to this company before?

Have you been employed at this country before?

If yes, when & which location?

Do you have any friends or family employed at this location?

Have you ever been convicted of a crime in last seven (7) years?

If yes, please explain (Convictions will Not Necessarily Be A Disqualification for Employment)

If considered for hiring, will agree to provide a criminal background check?

Educational Background

List previous three (3) educational institutions attended, beginning with the most recent.

CITY, STATE/PROVINCE

DEGREE(s)/DIPLOMA(s) EARNED

What Nursing or relevant licenses, certifications or registrations if any, do you possess?

Date of Most Recent Registration

Do you have the following:

PLEASE ANSWER THE FOLLOWING QUESTIONS

What do you think is the most difficult part of nursing or customer service work?

Think of the BEST supervisor you have ever had, what characteristics made that person a good manager?

Think of the WORST supervisor you have ever had, what characteristics made that person a poor manager?

How will you be able to contribute to providing our home care clients with high quality care?

EMPLOYMENT BACKGROUND

Provide the following information beginning with the most recent employer.

SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES

IMMEDIATE SUPERVISOR AND TITLE AND PHONE NUMBER

MAY WE CONTACT FOR REFERENCE?

Select Yes No Later

SUMMARIZE THE TYPE OF WORK PERFORMED AND JOB RESPONSIBILITIES

IMMEDIATE SUPERVISOR AND TITLE AND PHONE NUMBER

MAY WE CONTACT FOR REFERENCE?

Select Yes No Later

Applicant's Signature

I certify that all the information I have provided is true, complete and correct. The information contained within this application or any cover letter or resume attached is not shared with any third parties. The information is used by the employer only as an aid in the hiring decision making process. The applicant, by signing the application gives the employer consent to collect the information contained herein and use for the purpose specified. / authorize this company to investigate all statements contained on this application. / understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal. / understand that if I am hired, I will be required to provide criminal background check, proof of identity and legal authority to work in the U.S, and proof of certifications or educational qualifications. Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not in any way constitute an agreement or contract for employment.

We are committed to providing high quality and client-centered services/care to our clients to enable them to lead dignified and independent lives in the comfort and safety of their own homes.

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We are committed to providing high quality and client-centered services/care to our clients to enable them to lead dignified and independent lives in the comfort and safety of their own homes.