CNS/CHHS Application

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Application for Employment and Request for Background Information

Please Type or Print and Please Complete All Sections

Name*

First NameLast Name

Middle

Maiden Name

Date of Birth*

Social Security Number (xxx-xx-xxxx)*

Home Telephone

Mobile Phone*

E-mail *

Professional License Number (if no license number please type N/A)*

Home Address for Past 10 Years - Please List Current Address First

If more than 2 addresses in the last 10 years they can be completed during interview

Current Street Address*

Apt/Unit

City*

State*

Zip Code*

From Month*

Year*

To Month*

Year*

Previous Street Address

Apt/Unit

City

State

Zip Code

From Month

Year

To Month

Year

Name of Employer #1*

Current or Most Recent

Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

From (MM/YYYY)*

To (MM/YYYY)*

Employers Phone*

Supervisor

Description of Duties/Responsibilities*

Name of Employer #2*

Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor

From (MM/YYYY)*

To (MM/YYYY)*

Phone*

Description of Job/Duties*

Name of Employer #3

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor

From (MM/YYYY)

To (MM/YYYY)

Phone

Description of Job/Duties

References

Please lsit three (3) individuals with whom you have worked with who were in a position to evaluate your performance.

First and Last Name of Reference*

Name of Company/Hospital/Agency*

Title/Position*

Phone Number*

First and Last Name of Reference*

Name of Company/Hospital/Agency*

Title/Position*

Phone Number*

First and Last Name of Reference*

Name of Company/Hospital/Agency*

Title/Position*

Phone Number*

First and Last Name of Reference

Name of Company/Hospital/Agency

Title/Position

Phone Number

Education

(List Most Recent First)

Name of School*

Address of School (Street Name/City/State/Zip Code)*

Degree or Concentration of Studies*

From Month*

Year*

To Month*

Year*

Name of School*

Address of School (Street Name/City/State/Zip Code)*

Degree or Concentration of Studies*

From Month*

Year*

To Month*

Year*

Name of School

Address of School (Street Name/City/State/Zip Code)

Degree or Concentration of Studies

From Month

Year

From Month

Year

General Information

Are you legally authorized to work in the USA?*

YesNo

Have you ever been convicted of a felony or misdemeanor or crime*

YesNo

(This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.) A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its occurrence and any rehabilitation you have undergone.

If yes, state the basis for each conviction and the date of the conviction:

Are you able to perform the tasks according to the job description without accommodation?*

YesNo

If an accommodation is needed, how would you perform the task and with what accommodation?

Availability

DaysNightsEveningsWeekends

Hours Desired:

Full TimePart Time

How did you learn of this opening?

Date you can start?*

Do you have any pediatric experience, anyone under the age 19, in the last three (3) years?*

YesNo

Military Branch?*

YesNo

If yes, Branch

Rank

Separation Rank

Occupation in Military Branch

In Case of Emergency - Contact Information*

In Case of Emergency - Contact Information

This institution does not discriminate in hiring or in any other decision on the bases of race, color, sex, citizenship, national origin,ancestry, Vietnam Era Veteran Status or on the bases of age or physical or mental disability unrelated to ability to perform the workrequired. No question on this application is intended to secure information to be used for such discrimination.

I understand that my employment is at will and that either party is free to terminate the employment relationship at any time withoutcause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on thisapplication form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three (3) days show satisfactoryevidence of identity and eligibility for employment.In connection with this request, I authorize all corporations, companies, credit agencies, educational institutions, persons, lawenforcement agencies and former employers to release information they may have about me and release them from any liability andresponsibility from doing so; further, I authorize the procurement of an investigative consumer report and understand that suchreport may contain information as to my background, mode of living, character, and personal reputation. Further information maybe available upon written request within a reasonable period of time.

Applicant Signature

Date

Comprehensive Nursing Services, Inc.

Comprehensive Home Health Services

Employment Record