Employment Form

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.

Date of Application *

Name *

Address *

City *

State

Zip *

Phone Number

Cell Phone

Email *

Referred by

In case of emergency who should we contact?

Name

Address

Contact Number

Have you resided in Missouri 5 years or more?

Yes

No

(If you have resided in another state, a nationwide criminal background check (to include open and closed records) will be completed).

If so, please list all previous states resided in, along with corresponding dates.

Are you at least 18 years of age

Yes

No

Can you legally work in the United States?

Yes

No

Have you ever been convicted of, or plead guilty to, found guilty of, and/or plead nolo contendere to a felony or misdemeanor, except for a minor traffic violation?

Yes

No

If yes, please explain

Have you ever been charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?

Yes

No

If yes, please explain

Have you ever been discharged (fired, laid-off, etc.) from a job?

Yes

No

If yes, please explain
(add attachment if necessary)

Have you ever had any professional or occupational license or certification suspended/revoked?

Yes

No

If yes, please explain
(add attachment if necessary)

Are you able to meet the attendance requirements of this job?

Yes

No

Are you able to perform the essential duties of this job, as listed on the job description?

Yes

No

Please list any registrations/licenses/certifications that you presently have and status (i.e. current, suspended, revoked, etc.)

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Yes

No

Have you ever used an alias (first and/or last name) or social security number other than the one used to apply for employment with JONES HOME HEALTH CARE, INC.? (Please list below: include maiden name, any/all married names used, and/all social security numbers used)

Do you consent to pre-employment background/criminal record check (including all open and closed records)?

Yes

No

Answering yes to any of the above will not automatically disqualify you for employment

Education

High School

Name and Location of School

Areas of Study

Year Attended

Date Graduated

College

Name and Location of School

Areas of Study

Year Attended

Date Graduated

Trade or Business School

Name and Location of School

Areas of Study

Year Attended

Date Graduated

Employment Desired: Please check the one that apply to you.

RN

LPN

CNA

MA

Care Technician

OTHER

Date available to work

Salary required $

Are You Employed

Yes

No

If Yes, may we inquire of your present employer?

Yes

No

Do you speak any foreign languages?

Yes

No

If Yes, in which language do you speak?

Physical Record

Do you have any physical defects that prelude you from performing any work for which you are being considered? Please explain.

Employment History
List complete employment history for the past seven (7) years, with the most recent job first.

Employment 1

From

To

Name and Address of Employer

Phone #

Salary

Position

Reason you left

Employment 2

From

To

Name and Address of Employer

Phone #

Salary

Position

Reason you left

Employment 3

From

To

Name and Address of Employer

Phone #

Salary

Position

Reason you left

Employment 4

From

To

Name and Address of Employer

Phone #

Salary

Position

Reason you left

Employment 5

From

To

Name and Address of Employer

Phone #

Salary

Position

Reason you left

Employment 6

From

To

Name and Address of Employer

Phone #

Salary

Position

Reason you left

Business References

Business Reference 1

Name

Address

Telephone Number

Business

How Long

Business Reference 2

Name

Address

Telephone Number

Business

How Long

Business Reference 3

Name

Address

Telephone Number

Business

How Long

Personal References

Personal Reference 1

Name

Address

Telephone Number

Business

How Long

Personal Reference 2

Name

Address

Telephone Number

Business

How Long

Personal Reference 3

Name

Address

Telephone Number

Business

How Long

Registration
Indicate license or certification for any profession, skill or trade.

Occupation

State

Expiration Date

License Number

State

Expiration Date

License Number

State

Expiration Date

If you have applied for state registration, please indicate date of application

Skills

If you have applied for state registration, please indicate date of application

Typing/WP

Medical Terminology

Computer Skills

Shorthand

Medical Transcription

Medical Assistant

List additional qualifications, skills and knowledge of equipment you may have to assist you with in-home healthcare.

Additional Certifications and/or Degrees

Attach Resume *

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.

Sign

Date

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.

Applicant Signature

Date

NO CONSIDERATION OF EMPLOYMENT WILL BE GIVEN TO ANY APPLICANT WHO DOES NOT SIGN STATEMENT