• Demographic Information

  • Application Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Demographic Information

  • Are you a United States citizen?*
  • Will you work in a home with a pet?*
  • If no, are you authorized to work in the United States?*
  • Do you have access to the internet?*
  • Are you at least 18 years old?*
  • Do you fluently speak and write the English language?*
  • Have you ever been convicted of, or pleaded no contest to a felony?*
  • Do you speak and/or write any other language, other than English?*
  • Do you have access to reliable transportation?*
  • Do you have a problem working with a client who smokes?*
  • Do you have a valid driver’s license?*
  • Do you have any allergies that would affect your ability to provide care in a patient’s home?*

  • Position / Availability

  • Position(s) Applied For:*
  • Desired Status:*
  • Desired Start Date:*
     - -
  • Rows

  • Please Check the Locations Where You Are Willing to Work

  • Please Check the Locations Where You Are Willing to Work*

  • Licensure

  • Has there ever been any adverse action(s) against any professional license(s) or certification(s) held by you?*
  • Have you ever been excluded from participation in Federal or State healthcare programs such as Medicare/Medicaid or any other governmental program?*

  • Education

  • Employment History

  • Currently Employed?*

  • Professional References

    List three persons other than relatives, whom you have known for at least one year and have worked with.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • TERMS AND CONDITIONS OF JOB APPLICATION:


    I certify that the statements and information furnished by me in this application are true and complete. I understand that any
    omissions, false or misstated statements and misrepresentations in this application or during any subsequent interview are grounds for
    refusal to hire, or dismissal from employment, at any time the Peak to Peak Home Healthcare, LLC becomes aware of the omitted,
    falsified or misstated statements or misrepresented information. In consideration of my employment, I agree to conform to the rules,
    policies and regulations of the Peak to Peak Home Healthcare, LLC. I understand that failure to abide by this employment requirement
    will result in disciplinary action or termination of employment and I acknowledge that my employment can be terminated, with or
    without cause, and with or without notice at any time, at the option of either Peak to Peak Home Healthcare, LLC or myself. I further
    understand that no policy, benefit or procedure contained in any employee handbook creates an employment contract for any period of
    time. I further acknowledge that the employer reserves the right to change the terms and conditions of employment, including the
    employee job duties, working hours and employment policies at any time.


    I hereby authorize Peak to Peak Home Healthcare, LLC to investigate fully all information contained in this employment application
    and to investigate and compile any other information that may bear upon my suitability for employment. I further authorize my past
    and present employers to furnish Peak to Peak Home Healthcare, LLC with my complete records of employment together with the
    reason for my separation and any and all information that such employers may possess concerning me and I release past and present
    employers and their officials, officers and agents from any and all liability or any damages that may accrue to me by reason of
    furnishing such information. I similarly release Peak to Peak Home Healthcare, LLC from liability or damages for compiling such
    information.


    I understand and agree that if I am employed, the employment relationship will be terminable at will by either party without notice or
    cause, notwithstanding any other oral or written statements by either party prior to, at, or following date of employment unless set out
    in writing, dated, and executed by both parties or their designated legal agents. Only the owner or administrator has such authority on
    behalf of Peak to Peak Home Healthcare, LLC.


    I understand that if offered a position with Peak to Peak Home Healthcare, LLC or from time to time during the course of my
    employment, I may be required, to the extent permitted by law and any applicable contract, to take a drug or alcohol screen, or similar
    test or examination, as a condition of hiring or continued employment.


    I understand that if offered a position with Peak to Peak Home Healthcare, LLC or from time to time during the course of my
    employment, I may be required, to the extent permitted by law and any applicable contract, Peak to Peak Home Healthcare, LLC will
    perform a criminal background check, Colorado CAPS check, I-9 form, employment eligibility verification, Office of Inspector
    General (OIG) Exclusion list check, National sex offender registry check, drug testing, and other State and accreditation required
    checks as needed. I understand that any unsatisfactory results from refusal to cooperate with or any attempt to affect the results of
    these pre-employment tests and checks will result in withdrawal of any employment offer or termination of employment if already
    completed.


    I understand that this application will be considered active for a period of six months only, and that I will not be considered for
    employment after six months from the date of this application unless I complete a new application at that time.
    My signature certifies that I have read and agree with the above statements. I authorize the verification of any and all information
    listed above.

  • Submission Date & Time*
     - -
  • Should be Empty: