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APPLICATION FOR EMPLOYMENT
American Home Health & Hospice Care, Inc.
American Home Health & Hospice Care, Inc. policy requires that employment, training and development, compensation, promotion and all other conditions of employment be provided without unlawful discrimination on the basis of race, creed, color, age, handicap, disability, citizenship, national or ethnic origin or any other basis as prohibited by law.
Please Print:
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
OTHER NAMES YOU HAVE USED:
ADDRESS, CITY, STATE, ZIP:
HOME PHONE NUMBER:
ALTERNATE PHONE AND/OR CELL PHONE NUMBER:
POSITION YOU ARE APPLYING FOR:
Are you legally eligible to work in the USA?
If you are under 18 years of age, can you provide proof of your eligibility to work?
Have you ever been employed at our agency? Provide date (s)
What is your availability?
Indicate the date that you will be available to begin work.
After reviewing the position Job Description, are you able to perform the essential functions of the position that you are applying for, either with or without accommodation (s)?
If you can perform the essential duties only with accommodation, how would you perform those duties and with what accommodations?
How were you referred to our agency?
If applying for a position that requires travel, do you have access to dependable transportation with auto insurance and a valid motor vehicle operator's license?
What wage/salary range are you requesting for this position?
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Have you ever been convicted of a crime, felony or misdemeanor?
In consideration for employment, AMERICAN HOME HEALTH & HOSPICE CARE, INC. is required by state law to obtain a copy of your criminal history. Except as required by state law, a conviction record will not necessarily be a bar to employment. Factors such as age, time of offense, the seriousness/nature of the violation and subsequent rehabilitation will be taken into account.
EDUCATION
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NAME AND LOCATION
YEARS COMPLETED
DID YOU GRADUATE
DEGREES OBTAINED AND/OR MAJOR
High School:
College:
Other:
List any Special Skills, certifications or other credentials that would qualify you to work for our organization:
PROFESSIONAL LICENSURE/CERTIFICATION
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TYPE: (RN, LPN, PT, OT etc.)
LICENSE NUMBER:
EXPIRATION DATE:
STATE OF ISSUE:
CERTIFICATION(S) such as HCA, CNA, Medical Assistant, etc.
LICENSE NUMBER:
EXPIRATION DATE:
STATE OF ISSUE:
OTHER (MSW, BSW, etc.)
STATE OF ISSUE:
EXPIRATION DATE:
LICENSE NUMBER:
Have you ever had disciplinary action taken against your professional licensure and/or certification?
If Yes, please explain:
Do you belong to a professional, trade, business, or civic association? If so, please list here:
THREE PERSONAL REFERENCES (Please do not include people who are related to you)
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NAME:
RELATIONSHIP:
YEARS KNOWN:
PHONE:
EMPLOYMENT HISTORY (Please list your employers, starting with the most recent. Include job related military experience)
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EMPLOYER INFORMATION (Please include address, telephone number, & your supervisor's name):
FROM (start month/year) & TO (last month/year):
JOB RESPONSIBILITIES & ENDING WAGE/SALARY:
REASON FOR LEAVING (Please indicate if we may contact the employer):
Do you have friends or relatives who currently work for AMERICAN HOME HEALTH & HOSPICE CARE, INC.?
Have you been convicted of or have you pleaded guilty to any moving violations within the past twelve (12) months?
If Yes, please explain:
Please read the statement below and sign it at the bottom (your typed first and last name will constitute your signature)
I agree that I have been informed of the requirement of the work for which I am applying and that the information on this application and corresponding attachments, if any, are correct and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration for employment and may result in immediate termination of employment if discovered at a later date.
I understand and acknowledge that my employment is "at will" and that employment is by mutual agreement of American Home Health and Hospice Care, Inc. and myself and I may resign at any time and American Home Health and Hospice Care, Inc. may terminate my employment at any time, with or without cause, for any reason.
I understand that, if offered employment, American Home Health and Hospice Care, Inc. will make or cause an agency on its behalf to make inquiries, including but limited to criminal history, public records, experience, or other qualifications of employment, including reasons for termination of past employment. I agree that my authorization here within releases American Home Health and Hospice Care, Inc. and its agent from any and all liability, from all companies, agencies, officials, officers, employees, and other persons who, in good faith, provide to us the above-mentioned information as requested in order to successfully complete a background investigation.
I understand that if I am offered employment by American Home Health and Hospice Care, Inc. a medical examination is required, and my employment is conditional on the satisfactory outcome of that medical examination. I also understand that if I am offered employment by American Home Health and Hospice Care, Inc. I must provide all the required information requested in order to be considered for employment. I also understand that American that American Home Health and Hospice Care, Inc. will make reasonable accommodation to the known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation would cause an undue hardship on the operation of American Home Health and Hospice Care, Inc., or the individual would pose a direct threat to the health or safety of himself/herself or of others that cannot be eliminated or reduced below the level of a direct threat by reasonable accommodation which does not cause undue hardship to American Home Health and Hospice Care, Inc.
I agree to take a drug and alcohol test if I have a worker's compensation injury while I am your employee. I agree, if employed by you, that if I ever make claims against you for personal injuries, upon your request, I shall submit to examinations by physicians of your selection. I will hold American Home Health and Hospice Care, Inc. harmeless from any claims, including, but not limited to, personal injury or illness as a result of my providing false or misleading information on this application.
I understand that this is an Application for Employment only, and that I have not been offered employment by American Home Health and Hospice Care, Inc.
I authorize persons, schools, previous employer(s) and organizations named in this application (and any accompanying attachments (if any) to provide any relevant information to American Home Health and Hospice Care, Inc. that may be required to arrive at an employment decision.
Signature of Applicant:
Date:
We are an Equal Opportunity Employer (EOE)
