Radiance Home Health Care, Health care services, Best Quality Health Care Services

Part 1: PERSONAL INFORMATION

Application Date

Date of Birth (Mandatory)

EDUCATION:

School Name

School Location

Course of Study

Years

Degree/Study

Diploma College: (Optional)

High School: (Mandatory)

Vo-Tech, Trade, or Certificate Program: (Optional)

Part 2: EMPLOYMENT HISTORY

Dates of Employment: From

Part 3: PROFESSIONAL REFERENCES

Persons who can furnish information about job performance. You authorize the Human Resources department to contact these individuals.

Part 4: APPLICATION QUESTIONS

1. Have you ever applied for employment with this Agency ? (Mandatory)

2. How many total hours a week are you available for work (Mandatory)

3. Are you legally eligible for employment in the United States ? (Mandatory)

4. How did you learn Radiance was hiring ? (Optional)

5. Are you willing to work: (Mandatory)

6. Position applying for: (Mandatory)

7. Was your last name different from your present name during the above listed jobs ? (Mandatory)

8. If Yes, what was your name ? (Mandatory)

9. Do you have reliable transportation ? (Mandatory)

10. Are you currently employed ? (Mandatory)

11. Have you ever been convicted of a crime in the last 5 years, barring employment in a Home Care and Community support agency? (Mandatory)

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

12. Are you capable of performing the job set forth in the job description ? (Mandatory)

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

13. Credentials/Specialized Skills: (Mandatory)

Summarize special job-related skills and qualifications acquired from employment or other experiences. If applicable, list all states in which licensed giving registration and expiration date.

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 GROUNDS 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.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

DATE/Signature: (Mandatory)

AGENCY EMPLOYMENT APPLICATION