Employment Application PERSONAL INFORMATION Name* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone*Are you 18 years or older*YesNo DESIRED EMPLOYMENT Poistion you are applying for:*Registered NurseMedication TechnicianCertified Nursing Assistant (CNA)Home Health AideLicensed Practical Nurse (LPN)Desired Salary*Start Date* Date Format: MM slash DD slash YYYY Have you ever worked for Blessed Angels Home Healthcare Services?*YesNoWho referred you to Blessed Angels Home Healthcare? Friend Employee Advertisement Government Placement Agency Internet Other CURRENT EMPLOYER Are you currently employed?*YesNoIf so, may we contact your current employer?YesNoCurrent EmployerName of last supervisorTelephoneReason for leaving EMPLOYMENT HISTORY List your last two (2) employers, assignments of volunteer activities, including experience. Explain any gap in employment in the comments section below. Name of Employer 1*Job Title*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code From* Date Format: MM slash DD slash YYYY To* Date Format: MM slash DD slash YYYY What was the nature of your work?*Hourly rateName of supervisorPhoneComments Name of Employer 2Job TitleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country From Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY What was the nature of your work?Hourly rateName of supervisorPhoneComments EDUCATION High School Name of School & LocationNumber of years attendedDid you graduate?YesNoMajorCollege | University Name of School & LocationNumber of years attendedDid you graduate?YesNoMajorProfessional Training Name of School & LocationNumber of years attendedDid you graduate?YesNoProfessional Certification PERSONAL REFERENCES Professional Reference 1 First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneRelationshipFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Professional Reference 2 First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneRelationshipFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY LICENSE & CERTIFICATION Check all that apply* Select All RN LPN GNA/CNA Other State*Enter the state of your license or licenses here:SKILLS The following information will help us place you where your skills, knowledge of nursing and preferences will be best suitedCan you do vital signs ?*YesNoCan you do nurses notes?*YesNoAre you CPR Certified ?*YesNoDo you have intensive care experience?*YesNoIn which of the following areas have you had experience? Select All Med/Surg OB/Gyn Oncology Emergency Room Have you had any special training in nursing? If so, what?PreferencesAre you a licensed driver?*YesNoWill you travel 30 minutes one way?*YesNoWill you work private duty cases?*YesNoSelect your days of availability* Select All Monday Tuesday Wednesday Thursday Friday Saturday Sunday Select the time of day you are available* Select All Morning ( 5AM - 10AM ) Afternoon ( 11AM - 4PM ) Evening ( 5PM - 11PM ) 24 / 7 How many hours a week do you wish to work?*Please enter a number from 4 to 168.Are you handicap in any way? If so, please describe:Have you been convicted of a crime in the last 5 years?*NoYesPlease explain (Will not necessarily prevent your employment)ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?*YesNo(Proof of eligibility will be required before employment) Please check the box* I certify that the facts contained in this application are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for a subsequent discipline up to and including dismissal from employment if discovered at the later date. I understand that if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Ageless Healthcare other than the owners is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owners. If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Blessed Angels Home Care. This application will remain on the active file for 60 days. If I am hired within this period, this form will be transferred to my individual personal file. If I am not hired or have not heard from this agency within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Blessed Angels Home Care. I do hereby give the employer and/or its agents, including consumer-reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but is not limited to, credit reports, criminal conviction records, motor vehicle driving records, and previous employment history. Further, I hereby release from liability and hold harmless Blessed Angels Home Care and, its representative, all persons and organizations/companies for furnishing such information. If required, I agree to a drug-testing prior to and during employment or for post-accident occurrences. The employer, Blessed Angels Home Care is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report, which includes information as to your character, general reputation, personal characteristics, and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.” Date Date Format: MM slash DD slash YYYY Δ
