Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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.