* = Required Information
Application for Employment
We are dedicated to a policy of nondiscrimination in employment on any basis including race, color, age, sex, religion, disability or national origin.
In case of emergency who should we contact?
Day
Evening
Weekend
Full-Time
Part-Time
PRN-Pool
Yes No
(If you have resided in another state, a nationwide criminal background check (to include open and closed records) will be completed).
Yes No
Yes No
Yes No
Yes No
Yes No

(add attachment if necessary)
Yes No

(add attachment if necessary)
Yes No
Yes No
Yes No
Yes No
Answering yes to any of the above will not automatically disqualify you for employment
Education
High School
College
Trade or Business School
RN
LPN
CNA
MA
Care Technician
OTHER
Yes No
Yes No
Yes No
Physical Record
Employment History
List complete employment history for the past seven (7) years, with the most recent job first.
Employment 1
Employment 2
Employment 3
Employment 4
Employment 5
Employment 6
Business References
Business Reference 1
Business Reference 2
Business Reference 3
Personal References
Personal Reference 1
Personal Reference 2
Personal Reference 3
Registration
Indicate license or certification for any profession, skill or trade.
Skills
Typing/WP
Medical Terminology
Computer Skills
Shorthand
Medical Transcription
Medical Assistant
Additional Certifications and/or Degrees


This form has been designed to comply with State and Federal Fair Employment practice laws prohibiting discrimination on the basis of an applicant sex or minority status. Questions directly or indirectly reflecting such status had been included only where needed to determine a bona-fide occupational qualification or for other permissible purposes. Such questions or parsley noted on the applications.
Confidentiality

Information including personal and medical information will not be discussed with anyone other than persons who have proper authorization, information in this application or its information will not be shared, or sold to anyone.
APPLICANT'S STATEMENT OF UNDERSTANDING AND SIGNATURE: False information provided or implied on an application form or material omission is grounds for immediate dismissal without further notice.
* I certify that my answers are true and complete to the best of my knowledge. If this application leads to employments, I understand that omission, false, or misleading information in my application and/or interview may result in my discharge/termination from employment.
* I understand and authorize JONES HOME HEALTH CARE, INC. to obtain a criminal history background check, closed record check, an EDL background check, and FCSR check, and FBI background check, if applicable. JONES HOME HEALTH CARE, INC. may contact my former employmer in connection with the consideration of my employment. All references are hereby authorized to release all information which they may have relevant to my employment and experience. I hereby release JONES HOME HEALTH CARE, INC., its employee, affliates, and successors, from any liability that my arise due to information provided by such references.
* I understand that this application remains current for only 60 days. At the conclusion of that time, If I have not heard from, JONES HOME HEALTH CARE, INC., and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.
* This application does not constitute an agreement or contract for employment for any specified period or define duration. I understand that no supervisor or representative of, JONES HOME HEALTH CARE, INC. is authorized to make any assurances to the contrary and that no other agreement(s) are valid unless they are in writing and signed by the owner/director.
* I agree that If hired, I will follow all state rules and regulations, company policies, rules, procedures, and all other directivies pertaining to my employment; I understand that, JONES HOME HEALTH CARE, INC. reserves the right to add, change, and /or delete any policies, procedures, work rules, and/or benefits at any time.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENTS
* I certify that I have read, fully understand, and accept all terms of the foregoing applicant's statement of understanding and authorization.
NO CONSIDERATION OF EMPLOYMENT WILL BE GIVEN TO ANY APPLICANT WHO DOES NOT SIGN STATEMENT

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