Employment Application

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Position applying for:

Registered Nurse (RN)License Practical Nurse (LPN)Medical Social Worker (MSW)Office StaffHome Health Aide (CNA)Homemaker / CaregiverOther (please specify)

Other (please specify)

Availability: (Check all that applies.)

Full-TimeLive-inPart TimeHourly (Come & Go)Others (specify)

Days Available:

Time Available

Others (specify)

How Did you know about us? Please check.

AdvertisementInternet SearchFriendRelativeWalk-InOtherFriend/RelativeSocial Media

Friend

Other

 

Current Address :

City :

State :

Zip :

Previous Address :

City :

State :

Zip :

 

Have worked for this company before? YesNo

If Yes, what was the reaon for leaving?

Are you currently employed? YesNo

Are you either a U.S. citizen or an alien authorized to work in the U.S.? YesNo

Have you been convicted of a crime? YesNo

Have you ever held any professional license under any other name in the US? YesNo

Have you or are you presently receiving treatment for drug or alcohol abuse? YesNo

Do you have a valid Illinois driver’s license? Or a valid out of state driver’s license? YesNo

Have you ever been hospitalized for treatment for a chemical dependency? YesNo

Do you have a malpractice insurance? YesNo

Have you ever filed a Workers Compensation Claim? YesNo

Do you drive your own car? YesNo

Do you have any impairment which would interfere with your ability to perform assignment for which you have applied for? YesNo

Do we have a permission to take a picture of you? YesNo

 

EDUCATION

 

Name and Address of School

Degree

Year Graduated

High School

College

Graduate

Others

 

FOREIGN LANGUAGE PROFICIENCY

 

Fluent

Good

Fair

Speak

Read

Write

 

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

 

Do you have experience working on patient with: (Check all that apply.)

Alzheimer’s /DementiaDiabeticIncontinenceStrokeBedriddenHospiceFoley CatheterLifting:ColostomyIleostomyTracheostomyCooking for ClientHospiceWheelchair AssistHoyer LiftDriving for ClientBed BathOxygenNebulizerOther

Lifting:

Other :

 

EMPLOYMENT HISTORY (Start from your most recent job.)

Employer 1

Dates Employed

Job Position

Address

Start Date

Final Rate

Contact Name

Relationship

Contact #

Can contact him/her?
YesNo

Job Description

Reason for Leaving

 

Employer 2

Dates Employed

Job Position

Address

Start Date

Final Rate

Contact Name

Relationship

Contact #

Can contact him/her?
YesNo

Job Description

Reason for Leaving

 

Employer 3

Dates Employed

Job Position

Address

Start Date

Final Rate

Contact Name

Relationship

Contact #

Can contact him/her?
YesNo

Job Description

Reason for Leaving

 

REFERENCES

List the names of persons that you are not related to and whom you have known for at least one year.

Name

Business Address

Position

Contact #

By submitting this form, I agree to the terms and conditions of the Investigation Information Release Authorization.

I certify that the facts in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained herein and the reference listed above to give you any and all information concerning my previous employment and any pertinent information they may have personal or otherwise and release all parties from all liability for any damage that may result from furnishing same to you.

Signature

Date Signed

Hire Date