Application for Employment

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Harper Thompson Home Health Care LLC is an Equal Opportunity Employer and is committed to excellence through diversity. We consider applicants without regard to age, color, creed, disabilities gender, marital status, nation origin, religion or veteran status.

Email *

Requirements for Employment *

Photo ID (Current/ Valid Ohio State Driver's License or ID)

Proof of current Auto Insurance

Social Security Card (The actual card, we do not accept photocopies)

Home Health Aide Certification or STNA License (Originals Only, we do not accept photocopies) *If you do not have either of the listed above, a Letter of Proof of working under the supervision of a RN from your previous (or current) employer can be submitted. Verification of experience will be conducted.

BCI/FBI Fingerprint Check (This will be at your own expense and you will be reimbursed for the BCI/FBI after 120 days of employment. Results should be sent directly to the agency. If you have lived outside of Ohio in the last 5 years you are required to have a BCI & FBI Check)

Health Physical (Current Physical must have been conducted in the last 12 months)

Two-Step Tuberculosis (TB) Test (Needs to have been conducted in the last 12 months OR a negative chest X-Ray conducted in the last 24 months.)

CPR/First Aid Certification (Completed certificate for both CPR and First Aid within the last 24 months (2 years). If you do not have this certification, classes can be arranged for you at your expense through this agency. The cost will be deducted from your first Three(3) paychecks if you choose not to pay out of pocket.)

Other:

Required

Do you have your own automobile? *

Yes

Do you have automobile insurance? *

Yes

Do you take public transportation? (Metro Bus) *

Yes

Do you take private call transportation (Lyft, Uber, etc.)? *

Yes

Personal Information

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Are you a U.S. Citizen? *

Yes

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

Yes

Have you ever been convicted of a felony? *

Yes

If Yes, when and why?

Date of Birth *

YYYY

Social Security Number *

If Selected for Employment, are you willing to do a Pre-Employment Drug Screening Test? *

Yes

Have you ever filled out an application with this agency before? *

Yes

If YES, when?

Do you have a spouse, relative or friend who is employed with this agency? *

Yes

If YES, please list name and relationship to individual?

Can you travel if the position requires? *

Yes

How far are you willing to travel?

Position

Position You Are Applying For: *

Home Health Aide

STNA

LPN

Available Start Date *

YYYY

Desired Salary (per/hour)$ *

Employment Desired *

Full-Time

Part-Time

Split-Shift

PRN

Day Shift

Night Shift

Shift Availability - Please list the times you are available to work. Please list AM or PM next to the time frame. *

Employment History - Start with Present to Last Job

Employer 1

Job Title

Dates Employed

Work Phone

Starting Pay Rate

Address

Supervisor

May we contact your Supervisor?

Yes

Clear selection

Reason for Leaving

Employer 2

Job Title

Dates Employed

Work Phone

Starting Pay Rate

Address

Supervisor

May we contact your Supervisor?

Yes

Clear selection

Reason for Leaving

Employer 3

Job Title

Dates Employed

Work Phone

Starting Pay Rate

Address

Supervisor

May we contact your Supervisor?

Yes

Clear selection

Reason for Leaving

Disclaimer

I certify that my answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as a necessity to arrive at an employment decision.

This application for employment will be considered active for a period of time, not to exceed 30 days.

I hereby understand and acknowledge that unless otherwise defined by applicable law, any employment with this company is of an "AT WILL' nature, which means that the employee may resign at any time and the Employer may discharge the employee at any time with or without cause. It is further understood that this "At Will" employment may not be changed by any written document or conduct unless such changes are specifically acknowledged in writing by an authorized Executive of the company.

If this application leads to employment, I understand that false or misleading information in my application or interview(s) may result in my release from employment. I also understand that I am required to abide by all rules and regulations of the employer.

Yes

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