Careers Form

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us. This is not an employment contract. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.

PERSONAL INFORMATION

Position(s) Applied For *

Name *

Date of Birth

Social Security Number

Current Address *

Street *

City *

State *

Zip *

Previous Address *

Street *

City *

State *

Zip *

Home Phone *

Work Phone

Cell Phone *

Alternate Phone

Emergency Contacts *

Name *

Phone *

Name *

Phone *

Valid Driver's License # *

State Issued *

Expiry Date *

Have you live in the state of Ohio for the last 5 years? If NO, an FBI fingerprinting is required

YES

NO

Nurse License # *

Issue Date *

Expiry Date *

Home Health Aides Only

Do you have proof of home health aide/ S.T.N.A/C.N.A training?

Yes

No

Have you worked under the supervision of a licensed Registered Nurse for two consecutive years within the last two years?

Yes

No

If Yes, Please Provide Company Name:

Have you have been given a copy of the job description for the position for which you have applied to review?

Yes

No

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes

No

AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or the number of hours worked.

What date are you available to begin work?

Please indicate the days of the week as well as the earliest and latest times that you are available for work.

	Monday	Tuesday	Wednesday	Thursday	Friday
Shift From:
To:

PREFERENCES

Please indicate all areas of the area in which you are willing to work:

North

South

West

East

Are you willing to provide service to a client with a pet?

Yes

No

If Yes, Which Ones:

Cats

Dogs

Are you willing to provide service to a client that smokes?

Yes

No

EDUCATION

Please select highest grade completed:

High School

School Name

City

State

Major / Subject

Graduate?

YES

NO

Vocational / Technical

School Name

City

State

Major / Subject

Graduate?

YES

NO

College / University

School Name

City

State

Major / Subject

Graduate?

YES

NO

For employment our minimum education requirement is either a GED or High School diploma.

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

Yes

No

If YES, may we contact?

Yes

No

Company Name

City

State

Phone Number

Date Employed From

Date Employed To

Job Title

Supervisor

Duties

Salary

Per

Hour

Week

Month

Reason for Leaving

SECOND MOST RECENT EMPLOYER

Company Name

City

State

Phone Number

Date Employed From

Date Employed To

Job Title

Supervisor

Duties

Salary

Per

Hour

Week

Month

Reason for Leaving

THIRD MOST RECENT EMPLOYER

Company Name

City

State

Phone Number

Date Employed From

Date Employed To

Job Title

Supervisor

Duties

Salary

Per

Hour

Week

Month

Reason for Leaving

Are you at least 18 years of age?

Yes

No

Have you been charged/convicted of a felony and/or misdemeanor/or served time?

Yes

No

If Yes, please describe.

City / State

Charge

Incident

City / State

Charge

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

Yes

No

REFERENCES (Do Not Include Relatives)

Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional references.

Full Name

Phone

Best Time of Day to Call

Relationship

Number of Years Known

Full Name

Phone

Best Time of Day to Call

Relationship

Number of Years Known

Full Name

Phone

Best Time of Day to Call

Relationship

Number of Years Known

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Alta Home Health Care LLC, and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

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Applicant Signature *

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Date *

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