Employee Application

First Class Health and Nursing Services Employment Application

Simpsonville, SC 29680 Telephone: 864-399-7011

Email: admin@gofirstclasshealth.com Website: www.gofirstclasshealth.com
Application Date*

MonthDayYear
Date
Applicant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Which position are you applying for?*
How did you hear about this position?*

EmployeeReferralSocial MediaOther
Which days are you available to work? Select all that apply.*

SundayThursdayMondayFridayTuesdaySaturdayWednesday
What hours are you available to work? Select all that apply.*

MorningNightsAfternoonWeekendsEveningsFlexible
If hired, when are you available to start?*

MonthDayYear
Date
Personal Information
Are you at least 18 years of age or older?*

YesNo
Date of Birth*

MonthDayYear
Date
Are you a U.S. Citizen or approved to work in the United States?*

YesNo
Do you have proof of eligibility to work in the United States?*

YesNo
Do you have any condition(s) which would require reasonable accommodations to perform the job duties associated with the position you are applying for?*

YesNoPrefer not to answer
If yes, please explain.
Do you have reliable transportation?*

YesNo
Have you ever been convicted of a criminal offense (felony or misdemeanor)? (A felony conviction and/or inclusion on the S.C. Abuse Registry may prevent employment).*

YesNo
If yes, please explain.
Job Skills and Qualifications
Please select any skills/experience that may be useful for the job you are seeking. Select all that apply.*

Acute careInjection administrationAssessment and skilled observationComplex wound careIV assessment and monitoringCosmetic Post op carePEG/J-tube feedingsFoley catheter insertion/monitoringInfection Control / Blood-borne PathogensTracheostomy careMedication AdministrationPatient/caregiver educationDementia trainingLong-term careMed-surgical experienceHome careTeaching/PreceptorCurrent CPR/BLS
Education and Training
High School Attended City/State Year Graduated / Degree Earned
College/University Attended City/State * Year Graduated / Degree Earned *
College/University Attended City/State * Year Graduated / Degree Earned *
Vocational School/Specialized Training* City/State * Year Completed * Degree/Certification Earned *
Current Professional License State/Number/Exp. Date
Current Professional License State/Number/Exp. Date
Current Certifications Expiration Date
Current Certifications Expiration Date
Previous Employment (Please upload CV/Resume Only)
Upload Resume Here

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References
Name (Personal Reference)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name (Personal Reference)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name (Professional Reference)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Name (Professional Reference)*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Application Completion
By signing below, I certify that all information provided in this application (and/or any other accompanying or required documents) is true and complete to the best of my knowledge. Any false or misleading statements on this application, on my resume or in my interview(s) will remove me from further consideration of employment or, if I am hereafter employed by First Class Health and Nursing Services, will result in termination of employment.

I authorize First Class Health and Nursing Services to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my experience either personal or professional.

I understand that this employment application does not represent a guarantee of employment.
Applicant Signature*

Clear
Date Signed*

MonthDayYear
Date
Please verify that you are human*
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First Class Health and Nursing Services Employment Application

Personal Information

Job Skills and Qualifications

Education and Training

Previous Employment (Please upload CV/Resume Only)

References

Application Completion