Employment Application -

Employment Application

We appreciate your interest in Shining Star Home Health Care. We are an equal employment opportunity employer. The company's policy is not to discriminate against any applicant or employee based on race, color, sex, religion, national origin, age, disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. This application form is intended or use in evaluating your qualifications for employment with us: Please answer all appropriate questions completely and accurately.
Date of Application*

MonthDayYear
Date
Position Applying for*
When are you able to start work?*

MonthDayYear
Name*

First NameLast Name
Which county are you available to work in?

Palm Beach CountyBroward County
Phone Number*

Cell Phone Home Phone
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you authorized to work in the United States?*

YesNo
Social Security Number
REFERRAL INFORMATION: How did you Hear about Shining Star Home Health?*
Have you worked for this company before?*

YesNo
Were you referred by an employee?*

YesNo

Desired Work Schedule: Enter TIME AVAILABILE *

	FROM:AM	TO: PM
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Current Employment:
Are you currently employed?*

YesNo
If yes, can we contact your employer?*

YesNo
Background and Employment History
High School
Name, city, State
Course of Study
Number of Years Attended
Certificate, Diploma, Degree?

YesNo
College or University
Name, city, State
Course of Study
Number of Years Attended
Certificate, Diploma, Degree?

YesNo
Training School/Other
Name, city, State
Course of Study
Number of Years Attended
Certificate, Diploma, Degree?

YesNo
Name of Employer*
Address (City State, Zip) Phone, Supervisors Name,
Phone
Job Title
Salary/Wages
$per hour, week, month
Start Date

MonthDayYear
End Date

MonthDayYear
Brief description of duties*
Address (City State, Zip) Phone, Supervisors Name,
Reason for Leaving?*
Name of Employer
Address (City State, Zip) Phone, Supervisors Name,
Phone
Job Title
Salary/Wages
$per hour, week, month
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Brief description of duties
Address (City State, Zip) Phone, Supervisors Name,
Reason for Leaving?
Professional References:

Please your three (3) professional references who are not related to you.
Name*
Name of Reference
Years Known*
Phone*
Relationship*
Name*
Name of Reference
Years Known*
Phone*
Relationship*
Name*
Name of Reference
Years Known*
Phone*
Relationship*
Applicant's Statement and Acknowledgement
Initial: ________________*   I certify that all of the information furnished on this application and during the application process is true, complete and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts called for may result in refusal to hire, if hired, may result in my dismissal at any time regardless of when the false answer or omissions are discovered.

Initial: ________________*   I recognize that this employment application is not an odder of employment. I agree that if I am hired by the company, I will be an at-will employee, meaning that either the company or I may end the employment relationship at any time with or without cause of notice.

Initial: ________________*   I further understand and agree that, except for my at-will employment status, if hired, my wages, hours, working conditions, job assignment(s), and compensation rate(s), will be subject to change by Shining Star HHC.

Initial: ________________*   I understand that the company may share eh information contained in this application with other company employee for employment and administrative purpose and hereby consent to such transfer.

Initial: ________________*   I hereby authorize, to the extent allowed by applicable federal state and local laws, Shining Star HHC to conduct its own investigation of my references, employment history and education and, further, authorize the references and prior employers I have listed to disclose to the company information related to my employment history and qualifications for the position for while i am applying, without giving me prior notice of such disclosure.
Name

First NameLast Name
Signature*

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By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.

Employment Application

Current Employment:

Background and Employment History

Professional References:

Applicant's Statement and Acknowledgement

Caregiver Competency Assessment Test