AHS- Employment Application

Employment Application
Name*

First NameLast Name
Birth Date*

MonthDayYear
Social Security #*
No dashes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
If under 18, can you after employment, submit a work permit?*

YesNo
Can you after employment submit verification of your legal right to work in the United States?*

YesNo
Job Interest
How were you referred to us?*

Search EngineSchoolSocial MediaEmployee ReferralOther
Position Desired?*

Registered Nurse (RN)Licensed Practical/Vocational Nurse (LPN/LVN)Certified Nursing AidePersonal Care Assistant
Desired Wage:
Professional License/Certification*
Educational Record
High Education Level Completed?*

High School Diploma or EquivalentCertifcate/DiplomaAssociate's DegreeBachelor's DegreeMaster's Degree or Higher
Most Recent School Attended*
Criminal History
Have you ever been convicted of a felony?*

YesNo
Have you ever been convicted of a misdemeanor involving theft?*

YesNo
Have you ever been convicted of a misdemeanor involving abuse, neglect, or mistreatment of an individual?*

YesNo
If you answered yes to any of the questions above, please list any conviction/s.
Please include date, place, and disposition.
Work Experience

Please list your last 3 employers beginning with your most recent or present employer. If currently employed, please type "Present" in the box labeled "End Date"
May we contact your present employer?*

YesNo
Employer #1 (begin with most recent or present employer)*
Employer #2
References

Please list two (2) references that are familiar with your work life.
Reference*
Reference*
Please upload legible copies of the following documents:
- Valid professional license or certification
- Photo identification (current driver’s license, state ID, or passport)
- Social Security Card
- Criminal Background Check
- Medical Physical (within the past 12 months)
- Two Step PPD documentation, chest x-ray, or blood testing
- CPR Certification
- Proof of COVID-19 Vaccination
- Completed I-9 form
- Completed W-9 form
**10 Panel Drug Screening required prior to first assignment**
Document Upload Portal*

Cancelof
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SUMBITTING THIS APPLICATION FORM: I understand that employment at AHS is at will and that either AHS or I can terminate the employment relationship or any time for any reason, with or without notice. I further understand that neither this application nor any other AHS communication I may receive constitutes an employment contract.
I authorize AHS to contact any or all of my references and former employers listed herein and inquire about my employment there. I release AHS and any employer or reference, which is contacted from any liability arising out of such enquiry or the response to such inquiry. I certify that the statements contained herein are true to the best of my knowledge and any false or misleading statement, receipt of unsatisfactory references, an unsatisfactory result of drug screening test, an unsatisfactory result of a criminal background check or a unsatisfactory result of the prescribed physical examination which reveals that I cannot perform the essential functions of my job with or without accommodation may result in discipline up to and including discharge.
By submitting this form, you acknowledge that you have read and agree to the terms set forth above.*

I agree
Should be Empty:

Employment Application

Job Interest

Educational Record

Criminal History

Work Experience

References