Application Date
SSN will be required at Interview

PERSONAL DATA



EMERGENCY CONTACT



JOB INFORMATION


Date Available

Previous Facility Types Worked (Check all that apply)

Assisted Living/Residential TreatmentHome CareHome Health CareHospiceNursing HomeRehab

Language Skills (Check all languages you speak)

EnglishSpanishOther

AVAILABILITY


Check the types of Assignments you are available for Full TimePart TimeLive-InPRN

Check the shifts you are available for

Check the days of the week you are available for

LICENSES AND CERTIFICATIONS


Expiration Date
Expiration Date
Expiration Date
Expiration Date
Has your license ever been suspended, revoked or under investigation?
If yes, please explain


WORK EXPERIENCE:

List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.


Current/Most Recent Employer

From
To
May we contact?
If no, why?
Supervisor Experience?
Are your employment records listed under another name?

Previous Employer 1

From
To
May we contact?
If no, why?
Supervisor Experience?
Are your employment records listed under another name?

Previous Employer 2

From
To
May we contact?
If no, why?
Supervisor Experience?
Are your employment records listed under another name?

Previous Employer 3

From
To
May we contact?
If no, why?
Supervisor Experience?
Are your employment records listed under another name?

Additional Comments

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.

Application Questions

Are you legally authorized to work in the USA?
Have you ever been convicted of a misdemeanor or felony?
Will you submit to and pass a criminal background check?
Will you submit to and pass a pre-employment drug test?

I understand that I must report any and all accidents and/or incidents to Guardian Angels of Home Health, Inc. NO MATTER HOW SLIGHT, and acknowledge this statement by checking this box.

Yes, I understand

Applicant Statement: (Please read carefully before submitting this application. Your signature will be required at the time of your interview)

I give Guardian Angels of Home Health, Inc. permission to use any information in this application to enable them and/or their agents to verify the information contained in this application. I also authorize present and former employers, educational institutions I have attended, any references that I provide, and any other persons to answer all questions asked by Guardian Angels of Home Health, Inc. with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment and/or my employment, Guardian Angels of Home Health, Inc. may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Guardian Angels of Home Helath, Inc., and/or its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Guardian Angels Home Health, Inc., I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Guardian Angels of Home Health, Inc. or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Guardian Angels of Home Health, Inc., at any time, can constitute a contract of employment. No representative or agent of Guardian Angels of Home Health, Inc., has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, to include an analysis for unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on these results.

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that any omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and may be cause for my immediate dismissal from employment.

By checking this box, I understand that my submission of this application adheres me to the above Applicant Statement and my signature will be required at the time of interview.

Yes, I understand