H&R Home Health Care- Employment Application

Employment Application

Please complete the form below to apply for a position with our care team.
Full Name

First Name, Middle InitialLast Name
Date of Birth

DayMonthYear
Phone Number
Format: (000) 000-0000.
Email Address
Current Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Position Applying For
Please specify "other"
Desired Salary
Desired Start Date

MonthDayYear
Do you have current and active licensure for position (if applicable)?
Do you currently have a client that you will be bringing with you?
Issuing State
License Number
Are you a U.S. Citizen?

Please select your availability

Employment History

Please use this section to provide information about your previous employment starting with your current or most recent job.
Employment details

CompanySupervisorPhone numberEmailJob title
Employment Start Date

MonthDayYear
Employment End Date

MonthDayYear
Responsibilities
Reason for leaving
Employment details

CompanySupervisorPhone numberEmailJob title
Employment Start Date

MonthDayYear
Employment End Date

MonthDayYear
Responsibilities
Reason for leaving
Employment details

CompanySupervisorPhone numberEmailJob title
Employment Start Date

MonthDayYear
Employment End Date

MonthDayYear
Responsibilities
Reason for leaving

Education

Please use this section to provide information about your previous education including the qualifications/certificates your have gained.
Do you have a High School Diploma, G.E.D. or equivalent?
High School/College

School nameStart dateFinish date
Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Area(s) of study/Degree
University

School nameStart dateFinish date
Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Area(s) of study/Degree
Other

School nameStart dateFinish date
Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Area(s) of study/Degree

References

Please use this section to provide a list of three professional references. H&R Home Health Care may contact references directly
Referee 1

Full nameRelationshipPhone numberCompany
Email
example@example.com
Referee 2

Full nameRelationshipPhone numberCompany
Email
example@example.com
Referee 3

Full nameRelationshipPhone numberCompany
Email
example@example.com

Criminal History
Do you have any criminal convictions or are you currently the subject of any police investigation in the US or abroad?
Are you currently the subject of any investigation or proceeding by anybody having regulatory functions in relation to health and social care professionals including a regulatory body abroad?
Have you ever been disqualified from the practice of a profession or required to practice it subject to specified limitations following a fitness to practice investigation by regulatory body abroad?
If you have answered YES to any of the questions above, please give further details.
I certify to H&R Home Health Care that the information provided is true and complete to the best of my knowledge, and I consent H&R Home Health Care in processing personal data about me for purposes related to my employment in line with the DATA PROTECTION ACT, 1998. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my refusal or termination of employment.
I understand that submission of this application, gives consent to H&R Home Health Care, to run a criminal background check as a condition in the consideration of my employment.