APPLICATION FOR EMPLOYMENT

This form should be completed carefully and completely. It is essential that we have complete information regarding your training and experience. Your present employer will not be contacted for a reference without your consent. Reasonable accommodations will be made for applicants when requested.

Items marked * are required.

PERSONAL INFORMATION
Name*: Classification*:
    Date of Application:
Present Address*:
Mailing Address:
Permanent Address
(If different than Present)
Phone No.* 2nd Phone No.
Pager No. PIN No.
Email

Are you legally authorized to work in the USA? Yes No

Should you become employed by Care IV Home Health, you will be required to provide documentation proving your identity and eligibility to work in the USA.

How were you referred to Care IV Home Health?*

Newspaper
Professional Journal
Direct Mail
Employee Referral
Job Fair/Open House- Location
Other Care IV Branch
Other Referral Source

Type of Assignment Desired: Date Available:

EDUCATION
  Name of School Location (City, State) Courses Taken Diploma, Degree or Certification Received
Vocational/Technical
College
Post Graduate
Professional Education
Certifications
         
Member of Professional Organizations, honors, volunteer, community service, or other qualifications.

PROFESSIONAL LICENSES
Type Organization or State Issued Date Issued Number
Have you ever had disciplinary action taken against you for any violations of the Practice Act pursuant to the state(s) that you have been or are currently licensed/certified in? Yes No
Are you currently under investigation for any violations? Yes No

EMPLOYMENT RECORD
(list last or present position first) If you have worked under any other name, please indicate where appropriate.
May we contact your present employer? Yes No Reason:
Present and Former Employer Dates Employed Salary Position and Duties Reason for Leaving
Name:

Address:

City/State:
Supervisor:

Phone:

From:

 From:
To:
 To:
Name:

Address:

City/State:
Supervisor:

Phone:

From:

 From:
To:
 To:
Name:

Address:

City/State:
Supervisor:

Phone:

From:

 From:
To:
 To:
Name:

Address:

City/State:
Supervisor:

Phone:

From:

 From:
To:
 To:
Name:

Address:

City/State:
Supervisor:

Phone:

From:

 From:
To:
 To:
Please explain any periods of unemployment:

PROFESSIONAL REFERENCES
Provide us the names of at least four (4) professionals, not related to you, with whom you have worked within the last three (3) years.
Name and Title Address Phone Number
Are you able to perform the essential functions of the job description applied for with or without accommodation?
Yes No
Have you been convicted of a felony (other than traffic violations) or been imprisoned during the last seven years?*
Yes No
AGENCY EXPERIENCE
Agency Name City Dates Facilities Assigned/Areas Worked
ORIENTATION EXPERIENCE
List all facilities where you have had orientation.
Facility Orientation Date
 
 
 
 
 
 
 
 

AVAILABILITY RECORD
Number of hours desired: In general, my shift preference is:
Best times to contact: Do not contact between:
Are you available to work: Weekends? Yes No
Holidays? Yes No
Do you have any responsibilities that limit your availability: Yes No
Do you have dependable transportation that you will use to fulfill your assignments: Yes No

EMERGENCY INFORMATION
Whom should we notifiy in case of emergency:
Name: Relationship:
Phone:    
Address:
City:
State:    
Zip:

LANGUAGES
List proficiency in languages other than English:
Speak Read Write
Speak Read Write
Speak Read Write
ACKNOWLEDGEMENT

Please read our application acknowledgement here. It will open in a new window.

I have read and agree to the terms of this employee agreement.

Applicant's Name*: Date*:

VOLUNTARY SELF IDENTIFICATION

The purpose of this form is strictly to help the Company comply with federal regulations concerning equal employment opportunity.  You are not obligated or required to fill out the form or return it to us and the fact that you do or do not fill out the form will not in any way affect your application or the Company’s hiring decision.  The form will not be identified as having been filled out or returned by you and will not be kept with your employment application or any other documents pertaining to you individually.  No information provided on the form will be used in the Company’s hiring decision.  The company is an equal opportunity employer and makes all employment related decisions without regard to race, sex, age, religion, color, national origin, citizenship, disability or any other factor prohibited by state, local or federal law.

If you choose to not answer any of these questions, you will not be subject to any adverse consideration.   
Please check all that apply.

Gender Male
Female
Origin

Caucasian
African American
Hispanic
Asian or Pacific Islander
Native American-Indian or Alaskan
Other

Armed Forces Vietnam Era Veteran
Other Veteran
Disability Disabled
Disabled Vietnam Veteran
Disabled Veteran
Unknown
Other

* I have completed the application, reviewed my information and am ready to submit my application to Care IV.