Careers Form

* Required Information

PERSONAL INFORMATION

Applicant Date *

First Name *

Last Name *

Current street address *

City *

Zip Code *

Home Phone Number *

Cell Phone Number *

Social Security Number *

Date of Birth

Email *

GENERAL EMPLOYMENT QUESTION

What position are you applying for? *

Do you have reliable transportation to job assignments?

Yes

Are you legally eligible for employment in the United States?

Yes

Do you have current valid job license/certification?

Yes

Has your professional (healthcare license/certificate) ever been suspended or revoked by any state?

Yes

Do you have access to a telephone, and will you respond to job assignments in a timely manner?

Yes

Are you capable of reading, writing, and understanding English as part of performing job related duties?

Yes

Do you speak any languages other than English?

Yes

Do you have hands-on experience providing care services?

Yes

Do you have any restriction which would interfere with your ability to perform the duties of the position for which you have applied for?

Yes

Do you have Professional Liability Insurance?

Yes

Carrier name

What is your preferred shift? *

Date available to start work *

What is the best contact time? *

PROFESSIONAL AND TECHNICAL INFORMATION

Are you employed now?

Yes

May we contact your present employer?

Yes

Are you licensed or certified in any capacity of health or home care?

Yes

State where you received your health or homecare license/ certification

What is the License/ Certification number?

Are you CPR certified?

Yes

Are you First Aid certified?

Yes

Have you had a current TB Test?

Yes

Do you have the test results available?

Yes

EDUCATION AND TRAINING

Have you obtained a high school diploma or GED certificate?

Yes

School Name

Location

Diploma

College/ University?

Yes

School Name

Location

Degree of your specialization

List any special trainings, skills, licenses and/or certificates that you are qualify for and can utilize in the job position for which you are applying)

THIS SECTION IS TO BE COMPLETED BY AN OFFICE ASSISTANT APPLICANT

Do you have typing skills/word processing skills?

Yes

How many words Per Minute

Do you have computer skills?

Yes

Type of software:

Have you completed a course in medical terminology/billing/coding?

Yes

IN CASE OF AN EMERGENCY

(Contact my spouse, friend, family member, room-mate.)

Name

Relationship

Address

Telephone Number:

Name

Relationship

Address

Telephone Number

WORK HISTORY FOR THE PAST FIVE YEARS

(In order of employment from most recent employer)

Name of most recent employer

Complete Street Address

Zip Code

Phone Number

Supervisor’s Name

Your Position

Work Performed

Employment Date, from

Starting Pay Rate

Employment ending date, to

Ending Pay Rate

Reason for leaving

Name of most recent employer

Complete Street Address

Zip Code

Phone Number

Supervisor’s Name

Your Position

Work Performed

Employment Date, from

Starting Pay Rate

Employment ending date, to

Ending Pay Rate

Reason for leaving

Name of most recent employer

Complete Street Address

Zip Code

Phone Number

Supervisor’s Name

Your Position

Work Performed

Employment Date, from

Starting Pay Rate

Employment ending date, to

Ending Pay Rate

Reason for leaving

**ACKNOWLEDGEMENT AND AUTHORIZATION*

I hereby declare that I can perform the job-related functions applied for in this application. I represent that the information/document provided in this employment application is true and complete. I understand that I am a “Conditional Employee” and I authorize LLLHS to process/receive verification of a satisfactory criminal background check and successfully obtain fingerprint card from you until final determination of employment status. In addition, any false information may disqualify me from further consideration for employment and may be justification for dismissal from employment if discovered later.

I understand that if accused of abuse/ wrongdoing while employed, I may be subjected to probe by an outside agency/dismissal.

I understand and agree that if I am hired; my employment is “at will” which means that it is for no definite period of time and may be terminated by me or LLLHS at any time for any reason, and LLLHS does not guarantee any specific number of hours or shifts and I may not be assigned as determined by LLLHS.

Electronically Initial

I understand that if I am hired, a client may decide not to utilize my services at any time and will inform LLLHS if this occurs. That decision is made solely by the client. I understand that disclosure of the reason(s) for any such a decision is at the sole discretion of the client and that I am not privy to that information. I understand and acknowledge that if this occurs; I may not be assigned to other clients. In the event I haveany concerns regarding my assignment to client; I will immediately bring my concerns to LLLHS’s attention.

Electronically Initial

I understand that if employed, I will abide by LLLHS policies and procedures as required. I will maintaincurrent CPR and First Aid certifications and submit my annual satisfactory TB Test result while employed by LLLHS, Inc. In addition, I will maintain current personal automobile insurance (if driving any vehicle for a client of LLLHS), and a current copy of my driving record.

Electronically Initial

Name of Applicant *

Date

Attach Resume (Optional)

Choose a file

Signature *

Clear

PERSONAL INFORMATION

GENERAL EMPLOYMENT QUESTION

PROFESSIONAL AND TECHNICAL INFORMATION

EDUCATION AND TRAINING

THIS SECTION IS TO BE COMPLETED BY AN OFFICE ASSISTANT APPLICANT

IN CASE OF AN EMERGENCY

WORK HISTORY FOR THE PAST FIVE YEARS

****ACKNOWLEDGEMENT AND AUTHORIZATION***

**ACKNOWLEDGEMENT AND AUTHORIZATION*