Employment Application PERSONAL INFORMATION Name* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone*Are you 18 years or older*YesNo DESIRED EMPLOYMENT Poistion you are applying for:*Registered NurseMedication TechnicianCertified Nursing Assistant (CNA)Home Health AideLicensed Practical Nurse (LPN)Desired Salary*Start Date* Date Format: MM slash DD slash YYYY Have you ever worked for Angels Care Home Healthcare Services?*YesNoWho referred you to Angels Care Home Healthcare Services? Friend Employee Advertisement Government Placement Agency Internet Other CURRENT EMPLOYER Are you currently employed?*YesNoIf so, may we contact your current employer?YesNoCurrent EmployerName of last supervisorTelephoneReason for leaving EDUCATION Professional Training Name of School & LocationNumber of years attendedDid you graduate?YesNoProfessional Certification LICENSE & CERTIFICATION Check all that apply* Select All RN LPN GNA/CNA Other State*Enter the state of your license or licenses here:SKILLS The following information will help us place you where your skills, knowledge of nursing and preferences will be best suitedCan you do vital signs ?*YesNoCan you do nurses notes?*YesNoAre you CPR Certified ?*YesNoDo you have intensive care experience?*YesNoIn which of the following areas have you had experience? Select All Med/Surg OB/Gyn Oncology Emergency Room Have you had any special training in nursing? If so, what?PreferencesAre you a licensed driver?*YesNoWill you travel 30 minutes one way?*YesNoWill you work private duty cases?*YesNoSelect your days of availability* Select All Monday Tuesday Wednesday Thursday Friday Saturday Sunday Select the time of day you are available* Select All Morning ( 5AM - 10AM ) Afternoon ( 11AM - 4PM ) Evening ( 5PM - 11PM ) 24 / 7 How many hours a week do you wish to work?*Please enter a number from 4 to 168.Are you handicap in any way? If so, please describe:Have you been convicted of a crime in the last 5 years?*NoYesPlease explain (Will not necessarily prevent your employment)ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?*YesNo(Proof of eligibility will be required before employment) Please check the box* I certify that the facts contained in this application are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for a subsequent discipline up to and including dismissal from employment if discovered at the later date. I understand that if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Ageless Healthcare other than the owners is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owners. If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Angels Care HomeHealth Care. This application will remain on the active file for 60 days. If I am hired within this period, this form will be transferred to my individual personal file. If I am not hired or have not heard from this agency within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Angels Care HomeHealth Care. I do hereby give the employer and/or its agents, including consumer-reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but is not limited to, credit reports, criminal conviction records, motor vehicle driving records, and previous employment history. Further, I hereby release from liability and hold harmless Angels Care HomeHealth Care and, its representative, all persons and organizations/companies for furnishing such information. If required, I agree to a drug-testing prior to and during employment or for post-accident occurrences. The employer, Angels Care HomeHealth Care is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report, which includes information as to your character, general reputation, personal characteristics, and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.” Date* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
