Download INDHHC Applications

Application #:
Interview Date & Time:
Job Offer:
Hire Date:
Independence Home Health LLC
Application of Employment
Independence Home Health LLC is an equal opportunity employer. Applicants are considered for employment without regard to
race, color, religion, sex, age, disability, national origin, or any other legally-protected status, unless such status constitutes a bona
fide occupational qualification. Independence Home Health LLC will comply with its legal obligation to provide reasonable
accommodation to qualified individuals with disabilities and for religious beliefs. Please complete all questions. Failure to answer all
questions may result in disqualifying your application.
Personal Information
Last Name
First Name
Address (Street/P.O. Box)
Middle Initial
City
State
Zip Code
SSN#
Home Telephone # (include area code)
Cell Telephone # (include area code)
Employment Information
Position Applying For (check appropriate box):
HHA
LPN
RN
Other:____________________________________
Are you 18 years of age or older?
Yes No Do you have a High School Diploma or GED? Yes No If yes, please list education
institute awarding the High School Diploma or GED:__________________________________________________________________
Are you legally authorized to work in the United States?
Yes
No
Will you now or in the future require sponsorship for employment visa status (e.g. H-1B visa status)?
Yes
No
Salary or Wage Expected for the position you are applying for $ __________ (per hour)
What shifts are you available for work? ____________________________________________________________________________
What date will you be available to work? __________________________________________________________________________
Have you previously been employed by Independence Home Health LLC?
Yes
No If yes, please list dates of employment
and position__________________________________________________________________________________________________
How did you hear about this employment opportunity?
Employment Job Board
Employee Referral (name of employee) _________________________________
Walk-In
Newspaper
Other:_______________________________
Criminal History
(A conviction, plea, or pending charges will not necessarily disqualify you from consideration for employment. The effect of a conviction, plea, or
pending charges will be assessed with respect to time, circumstances, seriousness of the offense, and job responsibilities and duties. However, your
failure to list a conviction will disqualify you from consideration for employment or will result in termination of employment if subsequently
discovered.)
Have you ever been convicted of or pled guilty to a felony or misdemeanor other than a minor traffic-related infraction?
If yes, state nature of the conviction or plea, the date, the court and the jurisdiction.
Conviction:
Plea:
Conviction Date:
Court:
Jurisdiction:
Yes
No
Criminal History (continued)
Do you have any pending charges for a felony or misdemeanor other than a minor traffic-related infraction?
If yes, state nature of the conviction or plea, the date, the court and the jurisdiction.
Pending Charge(s):
Date:
Court:
Yes
No
Jurisdiction:
Reference Information
List three (3) personal references (non-family members)
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Phone#
(
)
Phone#
(
)
Phone#
(
)
Education/Training
Name of High School:
City, State:
Major/Degree:
Years Completed:
Name of College/University:
City, State:
Major/Degree:
Years Completed:
Name of Trade/Business School:
City, State:
Major/Degree:
Graduated:
Yes
No
Yes
No
Yes
No
Years Completed:
Professional Licenses, Registrations, and/or Certifications
Nursing:
Type (check appropriate box):
CNA
RN
LPN
HHA
State Issued (if yes, list
state):
Yes
No
State:
CNA
RN
LPN
HHA
Yes
State:
Date Issued:
(mm/dd/yyyy)
Expiration Date:
(mm/dd/yyy)
Document Number:
No
Other:
Type:
Date Issued:
(mm/dd/yyyy)
Expiration Date:
(mm/dd/yyy)
Institution (ex: college, trade school,
state agency):
Employment History
Starting with your present or most recent, list all your employment experience, including part-time or temporary employment for
the past 5 years. Resumes may be submitted but will not be accepted in place of the information requested below.
Employment Dates:
Work Performed:
Employer:_____________________________________
From:__________________
Address:______________________________________
Telephone:____________________________________
To:____________________
Salary/Hourly Rate:
Job Title:______________________________________
Starting:________________
Immediate Supervisor:___________________________
Final:___________________
Employment Dates:
Reason for Leaving:
Discharged
Voluntary Resignation
Involuntary Resignation
Work Performed:
Employer:_____________________________________
From:__________________
Address:______________________________________
Telephone:____________________________________
To:____________________
Salary/Hourly Rate:
Job TitleX
Starting:________________
Immediate Supervisor:___________________________
Final:___________________
Employment Dates:
Reason for Leaving:
Discharged
Voluntary Resignation
Involuntary Resignation
Work Performed:
Employer:_____________________________________
From:__________________
Address:______________________________________
Telephone:____________________________________
To:____________________
Salary/Hourly Rate:
Job Title:______________________________________
Starting:________________
Immediate Supervisor:___________________________
Final:___________________
Employment Dates:
Reason for Leaving:
Discharged
Voluntary Resignation
Involuntary Resignation
Work Performed:
Employer:_____________________________________
From:__________________
Address:______________________________________
Telephone:____________________________________
To:____________________
Salary/Hourly Rate:
Job Title:______________________________________
Starting:________________
Immediate Supervisor:___________________________
Final:___________________
Employment Dates:
Reason for Leaving:
Discharged
Voluntary Resignation
Involuntary Resignation
Work Performed:
Employer:_____________________________________
From:__________________
Address:______________________________________
Telephone:____________________________________
To:____________________
Salary/Hourly Rate:
Job Title:______________________________________
Starting:________________
Immediate Supervisor:___________________________
Final:___________________
Reason for Leaving:
Discharged
Voluntary Resignation
Involuntary Resignation
May we contact the employers listed above? Yes
No If no, indicate which one(s) you do NOT wish us to contact and provide
the reason why you prefer that we not contact the employer(s).
Have you ever been discharged, permitted to resign rather than be discharged, or asked to resign from any position?
yes, please state the employer and the reason for the discharge or resignation.
Yes
No If
Consent and Agreements
I hereby consent to a release of information from law enforcement agencies, the criminal justice system, be It federal, state or local
to Independence Home Health LLC, of any prior criminal history, arrest record, or Child Protection Service History.
I authorize Independence Home Health LLC to contact my references, current and past employers and release all parties from
liability for damage(s) that may result from furnishing information concerning my current and/or present employment and any
pertinent information they may have, personal or otherwise.
Applicant Signature:______________________________________________________________Date:_________________________
I understand that as a normal part of the hiring process the driving records of all prospective employees are reviewed. In addition, I
understand that my driving record is subject to future, periodic reviews. By completing and signing this form I give permission to
Independence Home Health LLC, and its insurance agent to obtain and review a copy of my driver license (MVR) both now and in the
future.
First Name:_____________________________ Middle Initial:______________________ Last Name:__________________________
Address:________________________________ City:_________________ State:____________ Zip Code:______________________
Date of Birth:__________________________ Driver License Number:__________________________ _State:___________________
Applicant Signature:______________________________________________________________Date:_________________________
Applicants with Licensure, Certification, or Registrations : CNA, LPN, RN, HHA
Are you currently or have you ever had your license under suspension, revocation, or had any other action against your professional
license in which you cannot practice without restrictions in any state? Yes No (if yes, provide dates of the
suspension/revocation and reason)_______________________________________________________________________________
____________________________________________________________________________________________________________
Applicant Signature:______________________________________________________________Date:_________________________
Independence Home Health LLC is an equal opportunity employer.