RN Employment Application

RN Employment Application
Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Home/Work Phone
Please enter a valid phone number.
Email*
example@example.com
Do you require sponsorship to work in the US?*

YESNO
Are you over the age of 18?*

YESNO
Date of Birth*

MonthDayYear
Date
Social Security Number*
XXX-XX-XXXX
Emergency Contact Name*
Emergency Contact Number*
Position Applying For:

Availability

	MON	TUE	WED	THUR	FRI	SAT	SUN
Morning
Afternoon
Evening
Night

Are there any specific hours/days that you are not available to work? If so, please list them:

Education
High School: City, State:
Years Completed: Major/Degree
Undergraduate: City, State:
Years Completed: Major/Degree
Graduate School: City, State:
Years Completed: Major/Degree
Trade School: City, State:
Years Completed: Major/Degree
Have you ever been convicted of a crime?*

YESNO
If yes, explain the number of convictions, the nature of the offense(s) leading to the conviction(s), how recently was/were the offense(s) committed, sentence(s) imposed, and type(s) of rehabilitation.
References

Please list any two references personal/professional references.
Reference Name 1*
Reference Position/Relationship*
Reference Phone Number*
Please enter a valid phone number.
Reference Name 2*
Reference Position/Relationship*
Reference Phone Number*
Please enter a valid phone number.

Employment History

Please list your work experience starting with your most recent employer.
Employer 1 Name*
City, State
Phone Number
Please enter a valid phone number.
Name of Last Supervisor
Employment Dates*
MM/YEAR - MM/YEAR
Starting Pay:
Ending Pay:*
Last Job Title
Job Duties and Responsibilities
Reason for Leaving
Employer 2 Name*
City, State
Phone Number
Please enter a valid phone number.
Name of Last Supervisor
Employment Dates*
MM/YEAR - MM/YEAR
Starting Pay:
Ending Pay:*
Last Job Title
Job Duties and Responsibilities
Reason for Leaving

Please list any additional skills, qualifications, certifications, or training that you feel is relevant to this position (e.g., speak a foreign language, CPR, or other training or special education:
******** PLEASE READ CAREFULLY ********

In exchange for the consideration of my job application by Care Star Healthcare, LLC, I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position. Both the undersigned and Care Star Healthcare, LLC may end the employment relationship at any time.*
PLEASE INITAL
I further understand that my employment with the company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary or thereafter, my employment relationship with Care Star Healthcare, LLC is terminable at will for any reason by either party.*
PLEASE INITAL
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Care Star Healthcare, LLC permission to contact schools, all previous employers (unless otherwise indicated), references, and perform a criminal background check conducted as required by state law. I hereby release Care Star Healthcare, LLC from any liability because of such contact.*
PLEASE INITAL
If I drive a vehicle for Care Star Healthcare, LLC, I will herein provide the following information:
- A copy of car insurance information
- Valid Driver's license
Signature*

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Date*

MonthDayYear
Date
Care Star Healthcare, LLC is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with Care Star Healthcare, LLC depends solely on your qualifications. Thank you for completing this application form and your interest in our business.

Emergency Contacts

Please provide two emergency contacts
Emergency Contact Name (1)*
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home/Work Number
Please enter a valid phone number.
Emergency Contact Name (2)*
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home/Work Number
Please enter a valid phone number.
I have voluntarily provided the above contact information and authorize Care Star Healthcare, LLC. and its representatives to contact any of the above on my behalf in the event of an emergency.

Job Description

Registered Nurse
Applicant Name*
Qualifications
- Registered Nurse
- BLS Certified
- Georgia RN License
- Clean criminal background check
- Negative TB test
- Signed statement of history of no misconduct
Responsibilities
- Taking verbal orders
- Participate in the development and implementation of the service plan for clients receiving nursing services
- Regularly assesses the needs of clients receiving Nursing services
- Medication Administration Teaching
- Monitoring medication
- Complete service plans
- Supervise CNAs and PCAs and Nurses
- Train new staff
- Supervise management of records
- Investigate incidents/grievances
- Investigate accidents
- Conduct orientation training
- Medication Administration Teaching
Signature*

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Date*

MonthDayYear
Date

NO Misconduct Statement
I, (Name), have never been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of application.
Signature*

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Date*

MonthDayYear
Date

TB & Hepatitis Acknowledgment
Staff must not go to the job site if he/she has been exposed to TB or Hepatitis. Staff must call the office. The office will assign another staff member until the regular staff member has a clearance from a Physician or health department that he /she can return to work. Once management receives the document from the Physician or health department that the staff member is not communicable, with TB or Hepatitis, the staff member will be able to return to work.

As an employee of Care Star Health Care, LLC, am aware of the TB and Hepatitis policy. If I am exposed to TB or Hepatitis, l shall adhere to the policy and not go to the work site. I will notify management of my condition and follow all directions given by management.
Signature*

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Date*

MonthDayYear
Date

Direct Deposit Authorization Form

Please complete ALL the information below.
Name of Bank:*
Account Number:*
9-Digit Routing Number*
Type of Account*

CheckingSavings
Care Star Healthcare LLC is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.
Signature*

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Date*

MonthDayYear
Date

W-9 Tax Form

1099 - Independent Contractor
1 Name as shown on your income tax return.*
2 Business name/disregarded entity name, if different from above.
3 Check appropriate box for the federal tax classification of the person who name is enter on line 1. Check only one of the following seven boxes.*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company.Other
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
XXX XX XXXX
Employer Identification Number (optional)
XX XXXXXXX
Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Signature*

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Date*

MonthDayYear
Date

ACKNOWLEDGEMENT OF APPLICANT’S NON-CRIMINAL JUSTICE PRIVACY RIGHTS AND CONSENT TO BE INCLUDED IN THE CAREGIVER PORTAL

Consent form to run background check on named applicant through the Department of Community Health Portal.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I hereby authorize the Georgia Department of Community Health (DCH), Office of Inspector General, to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. I understand a State and Federal fingerprint criminal background check will be conducted. By signing below, I am indicating that I have read and understand the terms and conditions of the attached Non-Criminal Justice Applicant’s Privacy Rights and Policy Act Statements.
SECTION II – CAREGIVER PORTAL - TO BE COMPLETED ONLY BY AN APPLICANT OR EMPLOYEE BEINGFINGERPRINTED AS PART OF FACILITY LICENSURE. DOES NOT INCLUDE OWNERS OR FAMILY EMPLOYERS.

The Georgia Caregiver Portal only contains the eligibility status of applicants and employees who have successfully passed the background screening process. The Caregiver Portal does not contain the names of applicants and employees who are ineligible. Family employers can access the Caregiver Portal to view a prospective applicant or current employee’s eligibility to determine their suitability for employment to provide personal care services to that employer’s elderly family member or wards. All services are performed at locations not licensed by DCH. Individuals should check one of the boxes below.
Please select one regarding family members access to your background check in the DCH portal.*

I agree to the results of my background check determination being available to family employers in the Georgia Caregiver PortalI am seeking employment only by licensed healthcare employers. I do not want or agree to the results of my background check determination being available to family employers.
Signature*

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Date*

MonthDayYear
Date

File Uploads

Please upload all needed files or email to management.
Driver's License (Background Check and I9 Verification)

Cancelof
Social Security Card (I9 Verification)

Cancelof
CPR Card

Cancelof
TB Test (within the last year)

Cancelof
Resume

Cancelof
RN License

Cancelof
Should be Empty:

RN Employment Application

Education

References

Employment History

Emergency Contacts

Job Description

NO Misconduct Statement

TB & Hepatitis Acknowledgment

Direct Deposit Authorization Form

W-9 Tax Form

ACKNOWLEDGEMENT OF APPLICANT’S NON-CRIMINAL JUSTICE PRIVACY RIGHTS AND CONSENT TO BE INCLUDED IN THE CAREGIVER PORTAL

File Uploads