SHH-Employment Application

PERSONAL INFORMATION
Full Name*
Date*

MonthDayYear
Date
Physical Address*
Mailing Address (if different than physical)
Email Address*
example@example.com
Phone Number*
Do you have reliable transportation?*

YesNo
Do you have automobile insurance as required by state law?*

YesNo
Do you have a clean driving record and a valid driver’s license?*

YesNo
If no, list restriction(s)
Are you 18 years of age or over?*

YesNo
If hired, can you provide evidence of your legal right to live and work in this country?*

YesNo
Do you have any relatives/friends working for Samaritan Home Health?*

YesNo
If yes, state name(s) and relationship
EMPLOYMENT DESIRED
Position*
Date available to start*

MonthDayYear
Date
Desired Hourly Rate or Salary*
Desired Hourly Rate or Salary*

Regular Full-Time Work (30+ hours per week)Regular Part-Time Work (20-30 hours per week)Per Diem
Availability (check all that apply)*

AM (days)PM (nights)Overnight
Availability (check all that apply)*

Monday-FridaySaturdaySundayOther
Are you able to perform the essential functions of the job for which you are applying?*

YesNo
EDUCATION, LICENSES, AND TRAINING
High School*
Graduate*

YesNo
Degree / Diploma*

YesNo
Undergraduate
Graduate

YesNo
Degree / Diploma

YesNo
Graduate
Graduate

YesNo
Degree / Diploma

YesNo
Doctorate
Graduate

YesNo
Degree / Diploma

YesNo
Other Education/License/Training
Graduate

YesNo
Degree / Diploma

YesNo
Indicate any foreign languages you can speak, read, and/or write
Have you obtained any special skills or abilities as a result of service in the military?*

YesNo
If yes, please describe
Do you have any other experience, training, qualifications, or skills that qualify you for this position or employment at Samaritan Home Health? Please describe.*
Are you licensed/certified for the position?*

Yes NoIf yes, please list information below. Use additional sheets if necessary.
License / Certification #1 Name
Issuing State
License / Certification Number
Has your license/certification ever been revoked or suspended, or are you currently involved in a proceeding that could affect your license or certification?

YesNo
If yes: Indicate the reason for revocation/suspension:
Date of revocation/suspension

MonthDayYear
Date
Date of reinstatement

MonthDayYear
Date
License / Certification #2 Name
Issuing State
License / Certification Number
Has your license/certification ever been revoked or suspended, or are you currently involved in a proceeding that could affect your license or certification?

YesNo
If yes: Indicate the reason for revocation/suspension:
Date of revocation/suspension

MonthDayYear
Date
Date of reinstatement

MonthDayYear
Date
Have you ever been excluded, debarred, suspended, or otherwise deemed ineligible to participate in federal/state health programs Medicare, Medi-Cal, etc., or in federal/state procurement or non-procurement programs, or do you have information that you may in the future be excluded, debarred, suspended, or otherwise declared ineligible?

Yes - reinstatedYes - not reinstatedNo
PROFESSIONAL REFERENCES
List three individuals, not related to you, who have knowledge of your work performance within the last 5 years.
Name (Reference #1)*
Occupation (Reference #1)*
Number of years acquainted (Reference #1)*
Phone Number (Reference #1)*
Email Address (Reference #1)*
example@example.com
Name (Reference #2)*
Occupation (Reference #2)*
Number of years acquainted (Reference #2)*
Phone Number (Reference #2)*
Email Address (Reference #2)*
example@example.com
Name (Reference #3)*
Occupation (Reference #3)*
Number of years acquainted (Reference #3)*
Phone Number (Reference #3)*
Email Address (Reference #3)*
example@example.com
EMPLOYMENT HISTORY

List all current and past employment starting with your most recent employer (last 10 years is sufficient).Account for all periods of unemployment. Include any related military service assignments and volunteer activities. You must complete this section even if attaching a resume.
Employer 1 Name*
May we contact for reference?*
Employer Location (City, State, Country)*
Employer email*
example@example.com
Employer Phone Number*
Your Job Title*
Dates of Employment*
Supervisor’s Name & Title*
Reason for leaving*
Employer 2 Name
May we contact for reference?
Employer Location (City, State, Country)
Employer email
example@example.com
Employer Phone Number
Your Job Title
Dates of Employment
Supervisor’s Name & Title
Reason for leaving
Employer 3 Name
May we contact for reference?
Employer Location (City, State, Country)
Employer email
example@example.com
Employer Phone Number
Your Job Title
Dates of Employment
Supervisor’s Name & Title
Reason for leaving
Please read carefully, initial next to each paragraph and sign below.

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Initials*
I hereby authorize Samaritan Home Health to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize the and other references I have listed to disclose to the company any and all letters, reports, information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
Initials*
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s Chief Executive Officer or his designee.
Initials*
Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment) be conducted by internal personnel employed by the company, I am entitled to copies of any such public records obtained by the company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.

I waive receipt of a copy of any public record described in the paragraph above.
Initials*
We provide equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws, we prohibit discrimination and harassment of any type.
Applicant’s Signature*

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Date*

MonthDayYear
Date
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PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION, LICENSES, AND TRAINING

PROFESSIONAL REFERENCES

EMPLOYMENT HISTORY