Employment Application

1950 Keene Rd Bldg M Richland, WA 99352
Phone: (509) 302-5770
Secure Fax: 1-855-395-0854
Email: office@hanfordhomehealth.com

Please complete the entire application below. It is the policy of Hanford Home Health to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, sexual orientation, national origin, age, disability, or veteran status.

Applicant Name*

First NameLast Name

Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code

Number of Years at Current Address*

Mobile Phone Number*

Please enter a valid phone number.

May We Text You at this Number?*

YesNo

Email*

Confirmation Emailexample@example.com

Social Security Number

Which language(s) do you speak with proficiency?*

EnglishSpanishOther

Name*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

Are you 18 years or older?*

YesNo

Are you legally eligible to be employed in this country?*

YesNo

Have you applied to Hanford Home Health previously?*

YesNo

Have you been employed at Hanford Home Health before?*

YesNo

Were you referred by someone to work with us?*

YesNo

If yes, please provide name of referral so we may thank them

First NameLast Name

Position Applying For*

Desired Wage Per Hour ($USD) *

Number of hours per week desired?*

Full Time (32-40 hours per week)Part Time (1-31 hours per week)Per Diem (Variable)

Desired shifts?*

DayshiftNightshiftOpen to either

Date available to start at desired employment level?*

Date

If hired, do you consent to driving record requests every two years and as needed?*

YesNo

Drivers License Number*

Drivers License Issuing State*

Do you have reliable transportation to and from work?*

YesNo

Do you own a vehicle in good working condition that is suitable for transporting clients?*

YesNo

If considered for hiring, will you agree to provide proof of vehicle insurance and maintain vehicle insurance throughout employment?*

YesNo

Personal Auto Insurance Carrier*

Policy #*

Policy Limits*

Current Expiration Date*

Date

Auto Insurance*

Are you willing to travel 15 miles to/from work if needed?*

YesNoOccasionally

Have you been convicted of a misdemeanor or felony, or are you currently out on bail, the subject of a current warrant for arrest or released on your own recognizance pending trial?*

YesNo

If hired, will you agree to random drug, alcohol, and criminal background checks?*

YesNo

What is the highest level of education you have completed?*

Which professional licensure/certification do you currently hold?*

Do you currently hold a valid, unencumbered license or certification for your profession that is free from any restrictions, disciplinary actions, or conditions?*

YesNo

If yes, current expiration date?*

Date

License/Credential Number:*

Do you have a valid BLS/CPR certification?*

YesNoNo, however will obtain prior to first date of employment

If yes, current expiration date?*

Date

Do you have a valid Food Workers Card?*

YesNoNo, however will obtain prior to first date of employment

If yes, current expiration date?*

Date

Are you physically able to perform competently and safely all Caregiver tasks including but not limited to lifting 50 lbs. or more?*

YesNo

If no, please provide any limitations

If no, what reasonable accommodation would you expect?

Are you available to work past your scheduled shift and/or unscheduled hours if required for emergent situations?*

YesNo

Resume Submission
Please upload a current copy of your resume that outlines your employment history, including relevant positions, responsibilities, dates of employment, and any applicable certifications or accomplishments. Your resume should reflect your most recent and past work experience to help us better understand your qualifications.

Please upload a copy of your current resume*

Professional Reference #1*

Professional Reference #2*

Professional Reference #3

Policy Agreement
I, the undersigned, certify that all the information I have provided is true, complete, and correct. I also understand that the information contained within this application or any cover letter or resume attached will not be shared by the company with any third parties. The information is used by the company only as an aid in the hiring decision making process. I, the applicant, by signing the application, give the company consent to collect the information contained herein and to use it for the purpose specified. I authorize company to investigate all statements contained in this application, including checking employment references. I understand that any misrepresentation or omission of facts called for is cause for immediate disqualification and/or if employed, immediate dismissal. I understand that if I am hired, I will be required to provide a criminal background check at my cost, proof of identity and legal authority to work in the United States of America, proof of certifications or educational qualifications, and a drivers license (if applicable). Furthermore, I understand and agree that if employed, I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same rights to terminate my employment at any time, with or without prior notice, except as may be required by law. I understand that this application does not in any way constitute an agreement or contract for employment.

I have read, and consent to, the above policies and conditions.

HANFORD HOME HEALTH

Demographics

Emergency Contact(s)

Refrences

Professional Reference #1

Professional Reference #2

Consent for Reference Check