Careers Form

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

PERSONAL

Last Name *

First *

Middle *

Date *

Street Address *

Home Phone *

City, State, Zip Code *

Mobile Phone *

S.S. # *

Date of Birth *

Email *

Emergency Contact (person not living with you) *

Emergency Contact Number *

Have you ever applied for employment with this Agency?

Yes

No

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

No

How did you learn of our organization?

I am looking to work

Day Shifts

Night Shifts

Position applying for: *

LPN

RN

Therapist

CNA

License #: *

Skills:

Procedure	Y/N Years Experience
Trachs
Peds
Geri
Home Care
Visits
Shifts
Wound Care
Feeding Tubes
TPN (RN ONLY)

Procedure	Y/N Years Experience
PCT Cardio ICU
Adolescents
Psych
Wound Vac
Prenatal
Dementia
Age Preference
Vents
LPN IV Certification? (Please provide copy)

EDUCATION *

Highest Level of Education Completed *

Year Degree Completed

Location where degree was completed

Additional Licenses

EMPLOYMENT *

List the last five years employment history, starting with the most recent employer.

1. Company Name

Telephone

Address

Dates of Employment
From

To

Starting Pay

Job Title

Reason for leaving

2. Company Name

Telephone

Address

Dates of Employment
From

To

Starting Pay

Job Title

Reason for leaving

3. Company Name

Telephone

Address

Dates of Employment
From

To

Starting Pay

Job Title

Reason for leaving

Was your last name different from your present name during the above listed jobs?

Yes

No

If Yes, what was your name?

Are you currently employed?

Yes

No

Do you have a reliable transportation?

Yes

No

PROFESSIONAL REFERENCES *

Persons who can furnish information about job performance

1. Name

Telephone

Address

2. Name

Telephone

Address

3. Name

Telephone

Address

GENERAL *

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency? *

Yes

No

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:

Are you capable of performing the job set forth in the job description?

Yes

No

If you answered No, which job requirement can you not meet?

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

Attach Resume

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUND FOR DISMISSAL

I Authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

DISCLAIMER

Nondiscrimination and Equal Employment Opportunity

It is the policy of Preferred Touch Home Care to ensure equal employment opportunity without discrimination or harassment on the basis of race, color, religion, sex, sexual orientation, gender identity or expression, age, disability, marital status, citizenship, genetic information, or any other characteristic protected by law. Preferred Touch Home Care prohibits any such discrimination or harassment.

I understand that I will not be discriminated against based on race, color, religion, sex, sexual orientation, gender identity or expression, age, disability, marital status, citizenship, genetic information, or any other characteristic protected by law.

E-Signature

Clear

Date

Voluntary Disclosure of Disability

Assurance of Confidentiality
The voluntary information collected for this form will be treated confidentially.

Definition of a Disabled Individual
The term Disabled Individual shall mean

An individual who: 1) has a physical or mental impairment which substantially limits one or more of such individual’s major life activities; or 2) has a record of such impairment; or 3) is regarded as having such an impairment.

Impairments include, but are not limited to:

Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular dystrophy
Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability

A disabled individual is considered “substantially limited" if he or she is likely to experience difficulty in securing, retaining or advancing in employment or education because of a disability.

Disclosure of Disability
I am a disabled individual as defined above on this form
I am not a disabled individual as defined above on this form
I wish not to disclose this information at this time

If applicable, the job related limitations or restrictions caused by my disability are:

E-Signature

Clear

Date

Voluntary Self-Identification of Protected Veteran Status

Assurance of Confidentiality
The voluntary information collected for this form will be treated confidentially.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act, In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed, please indicate by checking the appropriate box below.

Please check all that apply.

Veteran status
Disabled Veteran - 1) a veteran of the U.S. military, ground, naval, or air service who is entitle to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans' Affairs;, or 2) a person who was discharged or released from active duty because of a service connected disability.
Recently Separated Veteran - a veteran during the three-year period beginning on the date of such Veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
Active Duty Wartime or Campaign badge Veteran - a veteran who served on active duty in the U.S. military, ground, navel, or air service during a time of war or in a campaign or expedition for which a campaign badge has been authorized under the laws of the administered by the Department of Defense.
Armed Forces Service Metal Veteran - a veteran who, while serving on active duty in the U.S. military, ground, navel, or air service, participated in a U.S. military operation for which an Armed Forces service metal was awarded pursuant to Executive Order 12985.
I do not identify as a protected veteran as outlined in the options above.
I wish not to disclose this information at this time.

E-Signature

Clear

Date

Monday	Tuesday	Wednesday
Thursday	Friday	Saturday
Sunday