High SchoolName:Name of High School* . Address: Street Address* City* State* Zip* Course of Study: Course of Study* Degree or Diploma: Please Select Degree (GED) Diploma (HS Diploma) * Did you graduate? Yes No* ; If No, indicate Last Year Completed? 9th 10th 11th 12th
CollegeName: Name of College Address: Street Address City State Zip Course of Study: Major/Concentration Degree: Degree Did you graduate? Yes No ; if No, indicate Last Year Completed? Freshman Sophomore Junior Senior
Present or most recent employer:Name of Employer: Employer Name Address: Street Address City State Zip Phone: Area Code Phone Number Reason for Leaving: Reason
Your Last Name then: Last Name then Job Title: Job Title Start Date: Date End Date: Date Supervisor's Name:Supervisor Name Ending Salary: Ending Hourly Rate
Contact for reference Yes No ; If No, why not? .
Have you ever pled guilty to or been convicted of any criminal offense? (other than minor traffic violations). Do not disclose (1) minor traffic violations (2) convictions or arrests that have been sealed or expunged. Yes No * If yes, please explain: Explanation Are you a U.S. citizen or an alien legally authorized to work in the U.S.A?Yes No*
Emergency Contact #1: Name: First Name Last Name Relationship: Relationship Address: Street Address City State Zip Telephone: Area Code Phone Number Instructions for contacting: Type a label
Emergency Contact #2:Name: First Name Last Name Relationship: Relationship Address: Street Address City State Zip Telephone: Area Code Phone Number Instructions for contacting: Type a label
Emergency Contact #3:Name: First Name Last Name Relationship: Relationship Address: Street Address City State Zip Telephone: Area Code Phone Number Instructions for contacting: Type a label
I hereby affirm that the information on this application (any accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on this application or during the hiring process may disqualify me from further consideration for employment and may even result in discharge if discovered at a later date.
I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment.
I understand that as part of the application process, information and references may be sought regarding my prior employment and other history, and that a criminal background check may be conducted and I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing of or use of such information.
I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.
I understand that if I signed this application, I have agreed that I never have been shown by credible evidence (court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually exploited, or deprived a child or adult or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of application.Signature: Signature* Zelda Peters, APRN, FNP-C, PMHNP-BCAdministratorcompletehomecareservices465@gmail.com(800) 347-1468