Solace Healthcare Solutions Job Application Logo

  • Solace Healthcare Solutions

    16 Greendale Rd #2, Boston, MA 02126, USA | T: (617) 506-5717 F: (800) 878-6987 | www.solacehealthcare.org

  • Personal Information

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  • Job Information

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  • License Type License/Certification #      State      Expiration Date   Pick a Date   

  • License Type License/Certification #      State      Expiration Date   Pick a Date   

  • Work Experience

    List your last two work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

  • Company/Employer Name 1      Date Employed from:   Pick a Date   To:   Pick a Date   
                   
    Title:      
    Describe duties and specialty areas:      
    Telephone #:      
    Pay Rate/Salary:  Hourly        Yearly      May We Contact:            
    Why      
    Reason for leaving:      If this was a home Health Care agency, name of agency:      
    Are your employment records listed under another name?         If yes, what name?      
    Supervisory Experience:              How often?      

  • Company/Employer Name 2      Date Employed from:   Pick a Date   To:   Pick a Date   
                   
    Title:      
    Describe duties and specialty areas:      
    Telephone #:      
    Pay Rate/Salary:  Hourly        Yearly      May We Contact:            
    Why      
    Reason for leaving:      If this was a home Health Care agency, name of agency:      
    Are your employment records listed under another name?         If yes, what name?      
    Supervisory Experience:              How often?      

  • Education History

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  • Emergency Contact Information

  • Personal and Business References

  • Additional Information:

  • Criminal History

  • Have you ever been convicted of violating any law that would prohibit you from working in the healthcare field?
    (Please omit minor traffic violations.)

  • The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes.

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  • ACKNOWLEDGMENT

    (Please read carefully and sign)

  • In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete.  I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

     I give QAZ Home Care Services permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by QAZ Home Care Services with regard to any of the subjects covered by this application.  I also understand that in connection with my application for employment or my employment, QAZ Home Care Services may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation.  I release QAZ Home Care, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

     In consideration of my employment and of my being considered for employment by QAZ Home Care , I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice.  I also understand that if employed, I will be an employee at will and employed for no definite period of time.  I understand that either QAZ Home Care Services or I can terminate my employment at any time, with or without cause and with or without advance notice.  I further understand that no communication, whether oral or written, by any representative of QAZ Home Care , at any time, can constitute a contract of employment.  No representative or agent of QAZ Home Care, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

     I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws.  If I receive an offer of employment, I agree that my continued employment may be contingent on the results.

     I understand that QAZ Home Care Services is not involved in the day-to-day supervision or decision concerning patient care or dentistry.  This remains with the Professional as part of the Professional’s practice.  The Professional fully indemnifies QAZ Home Care Services against any and all liability and responsibility associated with his or her professional duties.  The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

     I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

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