CNS Application - Private Duty

Please upload your resume here if you have not already submitted it. If you are unable to upload you may bring a copy with you the day of your interview. Thank you

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*

Date

Social Security Number (xxx-xx-xxxx)*

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 Address*

Street Address

Apt or Unit Number - if applicable

CityState / Province

Postal / Zip Code

From Month*

Year (YYYY)*

To Month*

Year (YYYY)*

Previous Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

From Month

Year (YYYY)

To Month

Year (YYYY)

Home Telephone

Email*

example@example.com

Mobile*

Professional License Number*

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

1st Reference Name*

First NameLast Name

Company*

Title or Position Held*

Phone Number*

Please enter a valid phone number.

2nd Reference Name*

First NameLast Name

Company*

Title or Position Held*

Phone Number*

Please enter a valid phone number.

3rd Reference Name

First NameLast Name

Company

Title or Position Held

Phone Number

Please enter a valid phone number.

School Attended*

School Address, City, State & Zip*

Degree or Certificate Earned*

Month Started*

Year Started (YYYY)*

Month Completed*

Year Completed (YYYY)*

School Attended

School Address, City, State & Zip

Degree or Certificate Earned

Month Started (please choose from drop down list)

Year Started (YYYY)

Month Completed (please choose from drop down list)

Year Completed (YYYY)

School Attended

School Address, City, State & Zip

Degree or Certificate Earned

Month Started (please choose from drop down list)

Year Started (YYYY)

Month Completed (please choose from dropdown list)

Year Completed (YYYY)

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 NO, and an accommodation is needed, how would you perform the task and with what accommodation?

Availability (check all that apply)

DaysNightsEveningsWeekends

If you checked Days, how many day hours?

If you checked Nights, how many night hours?

If you checked Evenings, how many evening hours?

If you checked Weekends, how many weekend hours?

Hours Desired:

Full TimePart Time

How did you learn of this opening? ex: Indeed, Monster, referred by, etc.*

If referred by, please type the person's name

Date you can start? Month MM* Day DD* Year YYYY*

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

YesNo

Did you serve in the Military?*

YesNo

If yes, Branch of Service

Separation Rank

Rank

Occupation

In Case of Emergency - Contact Information

Full Name - Emergency Contact 1*

Relationship*

Telephone*

Address

Full Name - Emergency Contact 2

Relationship

Telephone

Address

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 work required. 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 without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three (3) days show satisfactory evidence of identity and eligibility for employment.

In connection with this request, I authorize all corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies and former employers to release information they may have about me and release them from any liability and responsibility from doing so; further, I authorize the procurement of an investigative consumer report and understand that such report may contain information as to my background, mode of living, character and personal reputation. Further information may be available upon written request within a reasonable period of time.

Applicant's Signature*

Date*

Date

Email (To receive a copy of your application, please type your email)

example@example.com

Comprehensive Nursing Services, Inc. Comprehensive Home Health Services

Comprehensive Nursing Services, Inc.

Comprehensive Home Health Services

Employment Record

References

Education

General Information