Employment Application

EMPLOYMENT APPLICATION

Heart of Humanity is An Equal Opportunity Employer. Applications are considered for all positions of employment wihtout regard to race, color, religion, sex, gender identificaiton, national origin, age, marital or veteran status, or non-job-related medical condidition or handicap.

Education & Military Experience
School/Location*
Enter your school where you obtained your highest level of education
Degree/Diploma*
Enter your degree or diploma earned
License
Select a valid license
Certificate

CPRRACSP
Certificate #
Enter certificate # if available
Have you served in the US Armed Forces?*

YesNo
Branch of Service
Special Employment Notice to Disabled Veterans and Individuals with Physical or Mental Handicaps

GOVERNMENT CONTRACTORS ARE SUBJECT TO SECTION 402 OF THE VIETNAM ERA VETERANS READJUSTMENTS ACT OF 1974 WHICH REQUIRES THAT THEY TAKE AFFIRMATIVE ACTION TO EMPLOY AND ADVANCE IN EMPLOYMENT QUALIFIED DISABLED VETERANS AND VETERANS OF THE VIETNAM ERA. AND SECTION 503 OF THE REHABILATATION ACT OF 1973; AS AMENDED, WHICH DICTATES THE SAME REQUIREMENTS FOR QUALIFIED HANDICAPPED INDIVIDUALS. IF YOU ARE A DISABLED VETERAN, OR HAVE A PHYSICAL OR MENTAL HANDICAP, YOU ARE INVITED TO VOLUNTEER THIS INFORMATION. ITS PURPOSE IS TO PROVIDE INFORMATION REGARDING PROPER PLACEMENT AND APPROPRIATE ACCOMMODATIONS TO ENABLE YOU TO PERFORM YOUR JOB IN A PROPER AND SAFE MANNER. THIS INFORMATION YOU ARE PROVIDING WILL BE TREATED AS CONFIDENTIAL. YOUR DECISION NOT TO PROVIDE THIS INFORMATION WILL IN NO WAY JEOPARDIZE OR ADVERSELY AFFECT ANY CONSIDERATION YOU MAY RECEIVE FOR EMPLOYMENT. PLEASE CHECK APPROPRIATE BOX AND SIGN IF YOU WISH TO BE IDENTIFIED.
PLEASE CHECK APPROPRIATE BOX AND SIGN IF YOU WISH TO BE IDENTIFIED

DISABLED VETERANVIETNAM ERA VETERANHANDICAPPED INDIVIDUALNone of the above
Signature

Work History
Current employer*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Supervisor's Name*
Position Held*
Start Date*

MonthDayYear
End Date

MonthDayYear
Reason for Leaving*
May we contact this employer for a reference?*

YesNo
Employer 2*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Supervisor's Name*
Position Held*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Reason for Leaving*
May we contact this employer for a reference?*

YesNo
Have you ever been fired, dismissed, terminated or had an employment contract terminated for performance or disciplinary reasons?*

YesNo

References
Work Reference 1*
Name of Reference
Phone Number*
Phone number
Email
example@example.com
May we contact this individual for a reference?*

YesNo
Work Reference 2*
Name of Reference
Phone Number*
Phone number
Email
May we contact this individual for a reference?*

YesNo

New Hire Job Requirements [TAKE SCREENSHOT]
Dear Employee, the following is required within 14 days of hire.
1. Current RN/L VN License or CHHA/CNA Certification (if applicable)
2. Current Physical Exam ( dated within the last 6 months)
3. Current PPD (TB skin test or chest x-ray) dated within last 12 months
4. Current CPR card (Cardiopulmonary Resuscitation)
5. Current Driver License or State ID card
6. Social Security Card, Permanent Resident Card, U.S. Passport or other acceptable document(s) for Employment Eligibility Verification (1-9)
7. Current Automobile Insurance with expiration date
8. Current Work References (2 are required)
9. Live Scan Report (all employees)
10. DMV Driver Record Report
11. Signed Employment Application
12. Complete Personnel Packet
13. Complete Orientation (in office)

Submit Application:
By clicking the submit button below, I authorize former employers, references and any other individual/organizations to provide information to Heart of Humanity Health Services Inc., and I hereby release and discharge any of the above and release Heart of Humanity Health Services Inc. from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a criminal background check, fingerprint, physical examination if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with Heart of Humanity Health Services Inc.

I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or currently authorized to work in the United States.

In consideration of my employment, I hereby certify that the information provided in this Application for Employment is true, correct and complete to the best of my knowledge. I understand that:
- This application is not a contract of employment. Nothing contained in this application or conveyed during any interview which may be granted or during employment, if hired, is intended to create an employment contract between me and the employer.
- If employed, any false or misleading statements or any omission of fact made herein or during subsequent interviews, may result in dismissal.
- Acceptance of an offer of employment does not create a contractual obligation upon the employer to continue my employment in the future.
- I am required, if employed, to abide by all rules and regulations of the Company.
I authorize any investigation of the information provided in this Application for Employment as may be required in reaching a decision regarding employment. If an investigative consumer reporting agency is engaged to report on my credit and personal history, I authorize you to do so. If a report is obtained, you must provide, at my request, the name and address of the agency so that I may obtain from them the nature and substance of the information contained in the report. In addition, I hereby release the employer, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application . I further agree in the event that I am hired by the employer, that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with the employer, whether during or after employment, including the solicitation or private hire of any employer clients will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written.

I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at the option of the employer.
Signature
Print full name*
Date*

MonthDayYear
Type a question
Should be Empty:

Personal Information

Education & Military Experience

Special Employment Notice to Disabled Veterans and Individuals with Physical or Mental Handicaps

Availability for work

Transportation

Abuse Investigation

Work History

References

New Hire Job Requirements [TAKE SCREENSHOT]

Submit Application: