TABB HEALTHCARE, LLC APPLICATION

EMPLOYMENT APPLICATION
Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Are you either a US citizen or authorized to work in the United States?*
Social Security Number*
Email Address*
Phone Number*

Area CodePhone Number
In case of emergency notify*

First NameLast Name
Relation of emergency contact to applicant*
Emergency contact address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency contact phone number*

Area CodePhone Number
Employment Desired
Please select desired position*
Desired wage per hour*
Date applicant is avaible to start employment*

MonthDayYear
Referred By
Please Upload a Current Resume

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Are you currently employed?*
May we contact your current employer?*
Have you ever applied to Tabb Healthcare, LLC before?*
Desired wage per hour*
Education
Name and Location of High School (Please include city and state)*
Number of Years Attended (High School)
Did you Graduate? (High School)*
Name and Location of College/Trade School (Please include city and state)*
Number of Years Attended (College/Trade School)*
Did you Graduate? (College/Trade School)*
Subjects Studied in College/Trade School*
General
Describe your experience working with individuals with intellectual disabilities*
List professional licenses, special skills and certifications currently held (CPR, First aid, wound care, etc) please include the expiration dates and license numbers where applicable*
Have you ever provided care to individuals requiring "total care" support? (to include but not limited to total/maximum support with all activities of daily living)*
Are you a licensed driver in the State of Virginia?*
Drivers License Number

Please indicate by marking all of the applicable boxes in the matrix below the experience you possess in providing the supports listed in the column in the left*

	YES I HAVE PROVIDED THIS SUPPORT	NO I HAVE NEVER PROVIDED THIS SUPPORT	I HAVE NOT YET PROVIDED THIS SUPPORT BUT I AM WILLING, CAPABLE, AND EAGER TO LEARN
Provided care to people who are Non-ambulatory
Performed range of motion exercise for an individual
Placed/Removed AFO's or splints
Used an ARJO and or Hoyer lift
Changed adult briefs (urine and feces)
Provided complete assistance with turning/repositioning
Provided oral suctioning
Rendered complete assistance with oral care
Made pureed or mechanically soft foods
Made thickened liquids
Provided care to people who must be fed
Cared for someone who requires a urinary catheter
Cared for people unable to eat by mouth (feeding tube)
Cared for someone who requires oxygen
Cared for someone with an artificial airway (breathing tube)
Driven a wheelchair van?
Driven a large wheelchair BUS?
Provided hand over hand assistance with all activities
Successfully communicated with nonverbal individuals

Have you ever been charged with or arrested for any criminal offense other than a minor motor vehicle violation? This question includes offenses which have been dismissed, discharged, or nolle prosequi. (ALL ARRESTS AND CHARGES MUST BE DISCLOSED AND EXPLAINED IF MORE ROOM FOR DOCUMENTATION IS NEEDED PLEASE NOTIFY YOUR INTERVIEWER UPON FIRST CONTACT)*
Please explain here if you indicated "YES" to the question above and you have been charged with or arrested for any criminal offense other than a minor motor vehicle violation, including offenses which have been dismissed, discharged, or nolle prosequi. (ALL ARRESTS AND CHARGES MUST BE DISCLOSED AND EXPLAINED IF MORE ROOM FOR DOCUMENTATION IS NEEDED PLEASE NOTIFY YOUR INTERVIEWER UPON FIRST CONTACT)
Do you have a history of substance abuse?*
If you answered yes to having a history of substance abuse please explain (if additional room is needed for documentation please notify your interviewer upon first contact)
Employment History

Please list your last three employers below, starting with the last one first
Full name and address of employer*
Date of hire*

MonthDayYear
Last day of employed (if currently still employed please enter todays date)*

MonthDayYear
Position held*
Salary (most recent)*
Reason for leaving *
Are you eligible for rehire with this company?*
Full name and address of employer*
Date of hire*

MonthDayYear
Last day of employed (if currently still employed please enter todays date)*

MonthDayYear
Position held*
Salary (most recent)*
Reason for leaving *
Are you eligible for rehire with this company?*
Full name and address of employer*
Date of hire*

MonthDayYear
Last day of employed (if currently still employed please enter todays date)*

MonthDayYear
Position held*
Salary (most recent)*
Reason for leaving *
Are you eligible for rehire with this company?*
Availability

Please mark all shifts that you are currently available to work at Tabb Healthcare, LLC

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
7am-3pm
3pm-11pm
11pm-7am

References

Please provide complete information of two former employers and one person not related to you, whom you have known at least one year
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Relationship/Business*
Years Acquainted*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Relationship/Business*
Years Acquainted*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Relationship/Business*
Years Acquainted*
Please carefully read the statement below in its entirety. After reading the statement provided please indicate that you have read, understand completely and agree with statement by marking the box adjacent to the statement "checked"*

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.
Please carefully read the statement below in its entirety. After reading the statement provided please indicate that you have read, understand completely and agree with statement by marking the box adjacent to the statement "checked"*

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my pervious employment and any pertinent information they may have, and release all parties from all liability for any damage that may result from obtaining this information.
Electronic signature of completed application*

First NameLast Name
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Personal Information

Employment Desired

Education

General

Employment History

Availability

References