Angel's Advocates Home Health Care Employment Application
Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Were you referred by a current employee?
*
Yes
No
Please give the name of the employee
First Name
Last Name
Have you previously been employed by Angel's Advocates Home Health Care?
*
Yes
No
Please state when and where
*
Did you learn about this position through an online posting?
*
Yes
No
Which One
*
Are you at least 18 years of age?
*
Yes
No
Are you legally eligible to work in the US?
*
Yes
No
Do you have a valid Driver's License?
*
Yes
No
Do you have an active automobile insurance policy?
*
Yes
No
Please provide name of insurance carrier and policy dates. (Proof of insurance will need to be presented if hired)
*
Number of accidents during the past 3 years?
*
Number of moving violations during the past 3 years?
*
Have you been convicted of a felony? (Conviction will not necessarily disqualify you from employment)
*
Yes
No
Please explain:
*
If selected for employment, are you willing to submit to a background check?
*
Yes
No
Job Preferences
Position Applying for:
*
Please Select
Home Health Aide
CNA
STNA
LPN
Have you completed any formal caregiver training?
Yes
No
Are you currently CPR certified or willing to obtain CPR certification?
Yes
No
Please upload proof or training, certifications or credentials:
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Available Start Date
*
-
Month
-
Day
Year
Date
Schedule Preferences
*
Full Time
Part Time
Seasonal
Other
Number of Hours per Week
*
Hours
Please indicate the times you are available to work
*
Rows
Morning
Afternoon
Evening
Other
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Desired Hourly Wage:
*
Have you been told or read the essential functions of the job and can you perform them?
*
Yes
No
Education
Level of Education Completed
*
High School
Trade/Vocational School
Some College
College (Associate or higher)
Graduate (Bachelor or higher)
Other
Education
*
Work History
Please include your past 5 years of Professional Work Experience
*
References
Please list at least three (3) professional references.
*
Declaration
I, the applicant undersigned, agree with the following statements:
*
I declare that all information provided in this form is true and complete to the best of my knowledge.
I understand that if I am employed, false statements, omissions or misrepresentations may disqualify me from further consideration for employment and may result in my dismissal if discovered later.
IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME. I UNDERSTAND MY EMPLOYMENT IS TENTATIVE BASED UPON A SUCCESSFUL COMPLETION OF A 10 YEAR CRIMINAL BACKGROUND CHECK AND BADGING PROCESS FOR ALL POSITIONS REQUIRING ACCESS WITH THE AIRPORT.
I acknowledge that I meet all required qualifications for this position and am able to perform the job responsibilities outlined in the job posting.
Incomplete applications will not be considered.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Appointment
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