Legal Name (Last, First, Middle Initial) *

Today's Date *

Cell Phone Number *

Address: Include Street Name, City, State and Zip Code *

Emergency Contact Name & Cell Phone # *

Social Security Number *

Date of Birth *

Race *

If other to the question above, specify.

Position Applying for: *

Are you 18 years old or older? *

Do you have a valid driver's license? *

What is your driver's license number? *

What city or county do you live in? *

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

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? *

Which schedule interest you? *

Are you available? *

If you're available on weekends, specify additional information. *

Check days available. *

Check shifts availability. *

Distance willing to drive. *

Have you ever been employed by A Nurse's Touch Home Care? *

Are you a licensed CNA, PCA or NA? *

Name any other licenses or certifications that may be relevant to this position. *

Clinical Experience. *

School Name (City, State, Required) High School, Graduate (Yes or No), College (Yes or No) *

List (Name) previous employers.... Include name, address, job title telephone number, (REASON FOR LEAVING) Beginning & Ending Compensation. *

Name language you speak, read and/or write. *

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. You fully understand that withholding information could disqualify you for employment. *

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? * If so, explain. *

Do you currently have felony charges pending? If yes, specify. * *

Are you currently on probation, if so, explain? *

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 time 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. *