Xincon EMPLOYMENT APPLICATION FORM

Xincon Home Health Care Services, Inc.

This application must be completed and all questions regarding your training and work experience answered. All information on this application is confidential, XINCON HOME HEALTH CARE SERVICES, INC. will not contact your present employer without your consent.

Name*

First NameMiddle NameLast Name

Gender*

FemaleMale

Street Address 1*

City

State

Zip Code

Cell Number

Please enter a valid phone number.

HomePhone

Please enter a valid phone number.

Other Phone

Please enter a valid phone number.

Email 1*

example@example.com

Email 2

example@example.com

Emergency Confact Name*

Relationship*

Emergency Contact Phone

Position applied for*

Administrative positionClinical PositionOther

Can you describe an example of a situation where you provided exceptional customer service/patient care?

Can you describe a situation in which you had to serve a difficult customer/patient? Which approaches did you use to deal with the situation?

Why do you think you will be a good fit for this position?

Please check off the below software(s) that you are proficiency in:

When are you available to work?

Date

Do you have more than 1 year Home Care experience?

YesNo

If Yes, do you have a UAS account?

YesNo

Please provide your UAS account user name:

Are you willing to assess patient that speak different languages using a translation line?

YesNo

How many cases per week are you looking to have?

Enter at least 2 areas that interest you the most (1 as your first choice, 2 as your second)
Manhattan
Queens
Bronx
Brooklyn
Staten Island
Long Island

Do you Drive?

YesNo

Preferred Scheduling Arrangement:

Self SchedulingDelegated Scheduling

What days are you available to work? (Please provide a specific time)
Monday   Type a label
Tuesday   Type a label
Wednesday   Type a label
Thursday   Type a label
Friday   Type a label

Are you available to work on weekends?

YesNo

If yes, which days are you available? (Please provide a specific time)
Saturday Type a label
Sunday Type a label

Have you ever applied for employment with this Agency?*

YesNo

Primary Language Spoken

Language Level

LowModerateFluent

Secondary Language Spoken

Language Level

LowModerateFluent

How many hours a week are you available for work

Minimum Salgry Requirement

Date Available

Date

Check if you have employment reference

Employer 1's Name

Address

Phone

Email

example@example.com

From Mo/Yr:

To Mo/Yr:

Job Title

Supervisor's Name

Salary (Optional)

Reason for leaving

Check here if you have a second employment reference

Type option 1

Employer 2's Name

Address

Phone Number

Please enter a valid phone number.

Email

example@example.com

From Mo/Yr:

To Mo/Yr:

Job Title

Supervisor's Name

Salary (Optional):

Reason for leaving

Check below if you have professional reference:

Type option 1

Reference Name

Email

example@example.com

Phone

Check below if you have second professional reference

Reference Name

Emoil

Phone

Are you currently employed? If Yes, by Whom:*

YesNo

If Yes, by Whom

Do you give permission for us to contact your previous employers and references listed above?

YesNo

Check below if you have professional licenses

Professional Licenses

Profession

Lic.No

Exp. Date

Date

Check here if you have a second professional license

Professional Licenses

Profession

Lic.No

Exp. Date

Date

School/Training Program

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed; falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I Authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any infor- mation they may have, and release all former employees and others listed above from all liability for any damage that result from furnishing the same to the Agency.

Iunderstand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Signature: XINCON HOME HEALTH CARE SERVICES, INC.does not discriminate because of sex, age, physical handicap, race, creed or national origin. The agency is an equal opportunity employer.

Signature*

Date

Xincon EMPLOYMENT APPLICATION FORM

Pre-Interview Questionnaire (General)

Skill Nurse/UAS Nurse Interview Questionnaire

Employment Reference

Professional Reference:

Professional Licenses