A Flourishing Life Health Care
Personnel File Sections and Forms
EMPLOYMENT APPLICATION
All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
PERSONAL
Date of Application
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last Name
First
Middle
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Street Address
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
City, State, Zip Code
Business Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact (person not living with you)
Have you ever applied for employment with this Agency?
Yes
No
How many hours a week are you available for work?
Are you legally eligible for employment in the United States?
Yes
No
How did you learn of our organization?
Online Ad
Agency employee
Other
If Other, please specify
Are you willing to work:
Evenings?
Weekends?
Position applying for:
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EDUCATION:
Education
Rows
School Name
Location of School
Course of Study
Degree/Diploma
College
College
Vo-Tech or Trade
Vo-Tech or Trade
High School
High School
Other
Other
Employment:
List the last five years employment history, starting with the most recent employer.
1.
Company Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Dates of Employment: From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dates of Employment: To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City
State
Zip Code
Starting Pay
Job Title and Describe your work
Reason for leaving
2.
Company Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Dates of Employment: From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dates of Employment: To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City
State
Zip Code
Starting Pay
Job Title and Describe your work
Reason for leaving
3.
Company Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Dates of Employment: From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dates of Employment: To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City
State
Zip Code
Starting Pay
Job Title and Describe your work
Reason for leaving
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Was your last name different from your present name during the above listed jobs?
Yes
No
If yes, what was your name?
Are you currently employed?
Yes
No
Do you have reliable transportation?
Yes
No
PROFESSIONAL REFERENCES
Persons who can furnish information about job performance
1.
Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
2.
Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
3.
Name
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
Yes
No
Conviction will not necessarily disqualify an applicant from employment.
If yes, describe in full:
Are you capable of performing the job set forth in the job description?
Yes
No
If you answered No, which job requirement can you not meet?
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CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
PLEASE READ ALL STATEMENTS BELOW BEFORE SIGNING THIS APPLICATION:
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I Authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time. I understand that a criminal background check will be performed for any position that has direct access to patients/clients or their personnel/medical information. By signing this application, I give permission for a criminal background check to be performed. I understand that if offered a position my employment may be conditional or terminated based on the results of my criminal background check.
DATE:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SIGNATURE
*
Submit Application
Should be Empty: