Employment Application

 

Date:

First Name:

Middle Name:

Last Name:

Last 4 Social Security Number:

Address

Street:

City:, State:
Zip Code:


Email Address:

Home Phone:

Cell/Other Phone:

Referred by:

Do you have a legal right to work in the United States?

Are you over 18 years of age?

In an emergency, please contact:
(Please list someone other than your client)
Name:
Phone Number:
Address:

EMPLOYMENT DESIRED

Position applying for:

Position Status:

License Information (if you are an RN, LPN, Therapist, Etc.)

Current Licensure as:

License #:

State(s):

Expiration Date:

Certification (CPR, Home Health Aide, Certified Nursing Assistant, Etc.)

Certified as:

Certification received:

Course Length:

Have you passed competency testing?

Do you have a current Driver License?

Do you have a Car?

Education

High School

Name and Location of School:

Degree Received:

Type of Certificate/Degree:

Major Emphasis of Studies:

College or University

Name and Location of School:

Degree Received:

Type of Certificate/Degree:

Major Emphasis of Studies:

Technical School

Name and Location of School:

Degree Received:

Type of Certificate/Degree:

Major Emphasis of Studies:

Other Schooling

Name and Location of School:

Degree Received:

Type of Certificate/Degree:

Major Emphasis of Studies:

Employment History

Are you presently employed?

May we contact your present employer?

(Please list your present or most recent employer first)

Employer's Name:

Employer's Address:

Employer's Phone Number:

Supervisor's Name:

Position Held:

Start Date:

Leave Date:

Hours Worked per Week:

Starting Salary: $

Ending Salary: $

Duties:

Reason for Leaving:


Employer's Name:

Employer's Address:

Employer's Phone Number:

Supervisor's Name:

Position Held:

Start Date:

Leave Date:

Hours Worked per Week:

Starting Salary: $

Ending Salary: $

Duties:

Reason for Leaving:


Employer's Name:

Employer's Address:

Employer's Phone Number:

Supervisor's Name:

Position Held:

Start Date:

Leave Date:

Hours Worked per Week:

Starting Salary: $

Ending Salary: $

Duties:

Reason for Leaving:

References

Please list below the names of three persons NOT RELATED TO YOU whom you have known for 3 or more years and are familiar with your work and education qualifications.

Reference's Name:

Reference's Address:

Reference's Phone Number:

Relationship to you:

Years Acquanted:


Reference's Name:

Reference's Address:

Reference's Phone Number:

Relationship to you:

Years Acquanted:


Reference's Name:

Reference's Address:

Reference's Phone Number:

Relationship to you:

Years Acquanted:


Special Questions

Are you a United States Citizen?

PLEASE CHECK ONE BOX TO EACH OF THE FOLLOWING QUESTIONS:
ARE YOU ABLE TO PERFORM EACH OF THE FOLLOWING JOB FUNCTIONS?:
(Examples of “Accommodations” would be a Hoyer Lift, Back Brace, Transfer Belt, Sliding Board, Etc.)

Transfers:



Lifting:



If you can perform the tasks with an accommodation, please explain how you would perform the tasks, and with what accommodations you would require:

AUTHORIZATION—PLEASE READ THE FOLLOWING AND THEN SIGN BELOW

I authorize an inquiry by an AmeriMed Home Care, Inc. representative to be made on the information contained in this application when it is used in consideration for employment. Former employers and references named herein are authorized to give information regarding me. They are hereby released from any and all liability for issuing such information.

I understand that this employment application and any other company documents are not contracts of employment. I understand and agree that the terms and conditions of my employment may be changed, with or without cause, with or without notice, at any time by the company. I understand that no company representative, other than its President, and then only when in writing and signed by the President, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that if hired, I may voluntarily leave employment upon proper notice. I understand that the company at any time and for any reason may terminate my employment and compensation, with or without cause, with or without notice, at the company’s sole discretion.

If employed by AmeriMed Home Care, Inc., it is understood that employment is conditional upon complying with the provisions of the Immigration Reform and Control Act of 1986. Accordingly, I will furnish proof of both my identity and my legal right to live and work in the United States of America.

I certify that all the information submitted by me on this application is true and complete, and I understated that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time.

I understand that if I am employed with the company that I am not to transport any clients that I am working for or with in my personal vehicle at anytime.

Today's Date:

Please re-enter the last 4 digits of your social security number in place of your signature for online submission:



Information

Information about AmeriMed Home Care, Inc. coming soon so check back often.