Application Employment Application Step 1 of 6 16% Applicant InformationName First Middle Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Position Applied For (Check One) RN / LPN Certified PCA, HHA, CNA PCA Training Office Staff Have you ever worked for or applied to this company? Yes No If yes, when? EducationPost High School Degree / Certificate Year Graduated High School Degree / Certificate Year Graduated ReferencesPlease list two references. (NO RELATIVES)Reference 1Full Name Relationship/Years known Address PhoneReference 2Full Name Relationship/Years known Address Phone Previous EmploymentMost Recent Company You Worked ForCompany Name PhoneAddress Supervisor Job Title ResponsibilitiesFrom To Reason for Leaving Company 2Company Name PhoneAddress Supervisor Job Title ResponsibilitiesFrom To Reason for Leaving Company 3Company Name PhoneAddress Supervisor Job Title ResponsibilitiesFrom To Reason for Leaving Other Information(Check one)Do you have any allergies? Yes No If yes, explain Do you have a fear of animals? Yes No If yes, explain Have you ever received training in HHA, PCA, or CNA? Yes No If yes, explain Do you have any experience in caring for the elderly, the disabled, or for children? Yes No If yes, explain Do you have any specialized training, certification, or licenses? Yes No If yes, explain Do you have a driver’s license? Yes No Do you have a car available? Yes No Are you interested in FULL or PART TIME employment? (Select one) FULL TIME PART TIME Days available (check all that apply): Monday Tuesday Wednesday Thursday Friday Saturday Sunday Shifts available (check all that apply) Day Evening Night Applicant’s StatementI certify that the information in this application is accurate, current, and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I authorize AfterCare Nursing Services (ANS) to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision. I authorize ANS to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize ANS to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release ANS and any individual or entity providing information to ANS from all liability for any damages from the disclosure of this information. I also understand and agree that: Passing a medical examination and/or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired, employment may be terminated. I may be subject to pre-employment drug testing or a drug test where a reasonable suspicion exists, or where warranted by circumstances, workplace conditions or contractual requirements. I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between ANS and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable "at will", that I will have the right to terminate my employment at any time, and that ANS will retain a similar right to terminate my employment at any time. I understand that I will not be paid wages for work performed after the date of my termination. I understand that should any work assignment be terminated for any reason, I am required to advise ANS within 24 hours, so I may be advised of my next assignment. Should I fail to advise ANS this constitutes my voluntary termination of employment. I understand that should I fail to report to an assignment without notifying ANS at least 8 hours prior to the start of the assignment, or if I should report for work later than the specified starting time for any reason on more than one occasion. I will be counseled and my employment may be terminated. I understand that ANS has a 24 hour per day answering service and I am responsible for waiting for a return call from a coordinator when calling off. I understand that should I become employed by ANS, my work assignments, schedules, and/or work locations are subject to change according to the needs of the business and the clients of AfterCare Nursing Services. I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment and contract between ANS and myself for either employment or for the providing of any ANS RESERVES THE RIGHT TO REFUSE EMPLOYMENT/TRAINING TO ANY APPLICANT WHO DOES NOT MEET OUR ELIGIBILTY CRITERIA. ANS IS AN EQUAL OPPORTUNITY EMPLOYER.Signature Type your full nameDate Δ
