A Nurse's Touch Home Care Employment Application
Email address *
Today's Date *
MM
/
DD
/
YYYY
Legal Name (Last, First, M.I) *
Your answer
Social Security Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Race *
Required
If "Other" to the above question, specify:
Your answer
Position Applying For *
Your answer
Are you 18 years or older? *
Do you have a valid drivers license? *
Drivers's License #:
Your answer
What city or county do you live? *
Your answer
Is there any additional information relative to change of name, use of any assumed name, or nickname necessary to permit a background check to your educational records? *
If yes to the above question, please provide any past name(s), & dates used so we may verify employment & education.
Name / From Date and To Date
Your answer
Your current address: *
Address, Street, City, State, Zip Code, Years at address
Your answer
Address (List other addresses from the past 7 years) *
Address, Street, City, State, Zip Code, Years at address
Your answer
Cell Telephone Number:
Your answer
Home Telephone No.
Your answer
Current Work Telephone Number:
Your answer
Can you produce evidence of the right to work *
Are you a citizen of the United States? *
Which location of A Nurse's Touch Home Care are you applying for: *
Required
What type of work are you interested in? *
Required
Are you available on weekends? *
Required
If you are available on weekends, specify additional information.
Your answer
Please check all days available: *
Required
Please check shift(s) available: *
Required
Willing to drive: *
Miles each day to work:
Your answer
Have you ever been employed with A Nurse's Touch Home Care? *
If yes... When? Which Town?
Your answer
Education
Licenses Certification: Are you a PCA, NA, CNA? *
Name any other license or certifications:
Your answer
Clinical Experience: *
Required
School Name (City, State Required)
High School...... Major/Minor.... Graduate(Yes/No)..... Grade Pt. Avg.
Your answer
School Name (City, State Required)
College ...... Major/Minor.... Graduate(Yes/No)..... Grade Pt. Avg.
Your answer
School Name (City, State Required)
Other ...... Major/Minor.... Graduate(Yes/No)..... Grade Pt. Avg.
Your answer
Employment
List last 4 employers:
List: Name, Address, Your Job Title, Telephone #, Reason for Leaving, Beginning/Ending Compensation, Dates of Employment
Your answer
Additional Space for the above question:
Your answer
Languages
Name the language you :
Speak, Write, Read
Your answer
Background Information
When completing this section, do not disclose information regarding convictions that have been judicially erased, sealed,
eradicated, impounded or dismissed. Do not disclose information regarding juvenile court convictions or minor civil traffic
violations. A conviction record does not automatically bar you from employment. All of the job related circumstances
surrounding convictions will be considered.
In the last 7 years, have you been convicted of, pled guilty or no contest to, been imprisoned, or on probation or parole for any felony? *
Your answer
In the last 7 years, have you been convicted of, pled guilty or no contest to, been imprisoned, or on probation or parole for any misdemeanor? *
Your answer
Do you currently have felony charges pending? If yes, specify. *
Your answer
Are you currently on probation? If yes, specify. *
Your answer
Authorization and Understanding:
By agreeing to this application, I agree that all of the information now or later given by me in support of my application for
employment is true and complete. I understand that you may verify any of the information concerning my employment,
education, credit or medical history with the appropriate individuals, organizations, or governmental agencies. I give these
individuals, organizations in the Commonwealth of Virginia or any other state, my permission to release any information
that you need, including my previous disciplinary record, without requiring them to contact me or give me written notice
before revealing the information to you. I understand that no verification of my credit history or request for a consumer
report under the Fair Credit Reporting Act may be undertaken by you without my express written authorization in a
separate document. By signing this application, and in the case of a consumer report under the Fair Credit Reporting Act,
should I sign the separate Authorization for credit reports on me, I release A Nurse's Touch Home Care from any
liability whatsoever arising out of any information request or disclosure. I agree that any false information in support of
my application may subject me to discharge at any time during my employment.
At-Will Employment Status *
I agree that either party may terminate the employment relationship, with or without cause, at any time, for any reason, and I further agree that this arrangement may only be changed by a supervisor, in writing, directed to me personally, and signed by the supervisor. I agree that I shall be bound by the other rules, policies, regulations, and terms and conditions of employment of the Company as they are from timie to time changed and that no additional obligations can be imposed by me on the Company except those which have been acknowledged, in writing, by the Company Supervisor or designated representative. I further agree that my employment is conditional upon satisfactory completion of employment physical (if such physical is required) are known. I AGREE THAT ANY CLAIM OR LAWSUIT RELATING TO MY SERVICE WITH A NURSE'S TOUCH HOME CARE or ANY OF ITS SUBSIDIARIES MUST BE FILED NO MORE THAN SIX MONTHS AFTER THE DATE OF THE EMPLOYMENT ACTION THAT IS THE SUBJECT OF THE CLAIM OR LAWSUIT. I WAIVE ANY STATUE OF LIMITATIONS TO THE CONTRARY. I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED.
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service