To finish the form offline, click here to download the PDF Download Employment Form "*" indicates required fields Step 1 of 6 16% X/TwitterThis field is for validation purposes and should be left unchanged.Qualifications for HireEmployee is at least 18 years of age.* I confirm Employee is able to read, write, and follow instructions.* I confirm Please check all past experiences that applyHas at least six months paid experience as: Agency Homemaker Nurse Aide Maid Has at least one year experience (paid or unpaid): Caring for Children Elderly Infirm Has successfully completed training as: Certified Nurse Aide LPN RN Interview NotesWe sometimes offer shifts on short notice. Would this be a problem? Yes No We must sometimes transfer heavy clients. Are you able to lift over 50 lbs.? Yes No Please give an example of your dependabilityHave you ever had to work with a difficult person? If so please explain how you handled working with this individualWhat is your 5 year goal plan?What is your availability?Please check the following counties in which you are available to work:* Wyandotte Johnson Leavenworth Miami Douglas Franklin Linn Atchison Jefferson We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.* I Agree I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employer and organization to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.* I Agree I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a complete pre-employment physical examination, my submitting a current negative tuberculosis test and my completion of any pre-employment mandatory training. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.* I Agree I also understand that I will be subject to a criminal background investigation, adult abuse registry check, National Sex Offender Registry, Office of Inspector General, and child abuse registry check prior to employment.* I Agree I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I UNDERSTAND THAT IF A CLIENT IS REMOVED FROM SERVICE, OR REQUESTS AN ALTERNATE WORKER, THERE IS NOTHING THAT ALLIANCE HOME HEALTH CARE, INC. CAN DO TO ALTER THE SITUATION. THIS SITUATION DOES NOT CONSTITUTE A TERMINATION OR RELEASE OF EMPLOYMENT ON THE PART OF ALLIANCE HOME HEALTH CARE, INC. AND THEREFORE DOES NOT ENTITLE THE EMPLOYEE TO UNEMPLOYMENT COMPENSATION. IF AN EMPLOYEE LOSES HOURS FOR ANY REASON IT IS THEIR RESPONSIBILITY TO CONTACT THE OFFICE EXPRESSING THEIR DESIRE FOR ADDITIONAL WORK. FAILURE TO DO SO WILL BE INTERPRETED AS A VOLUNTARY TERMINATION OF EMPLOYMENT. BY SIGNING BELOW, I ACKNOWLEDGE THAT THERE IS NO GUARANTEE ON THE AVAILABILITY, REGULARITY, OR TIMELINESS OF EMPLOYMENT HOURS* I Agree I have read, understand, and by my signature consent to these statements. This application for employment will remain active for a limited time. Ask the organization representative for details.* I Agree Signature*Your NameYour NameYour NameYour Name Personal InformationName* First Middle Last Other Names Used (Include aliases, maiden & nick names)*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Work Phone*Social Security #*Have you used any names or Social Security Numbers other than given above? Yes No List Here:Employment DesiredPosition(s) Applied For*Date of Application* Are you currently employed? Yes No May we contact your present employer? Yes No Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?* Yes No Explain:On what date would you be available for work?Have you ever been convicted of any law violation? (Include any plea of guilty or no contest. Exclude minor traffic violations.) Note: A conviction will not necessarily disqualify an applicant for employment.* Yes No Gives Dates, Court Locations and Sentence.Explain Employment Experience List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from current and former employers. Employment Experience 1Employer (Current or last)Employed From Employed To Hourly Rate/Salary StartHourly Rate/Salary FinalAddressCity/State/ZipPhoneEmployment Verification Yes No Job Title and DutiesSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for LeavingEmployment Experience 2Employer (Current or last)Employed From Employed To Hourly Rate/Salary StartHourly Rate/Salary FinalAddressCity/State/ZipPhoneEmployment Verification Yes No Job Title and DutiesSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for LeavingEmployment Experience 3Employer (Current or last)Employed From Employed To Hourly Rate/Salary StartHourly Rate/Salary FinalAddressCity/State/ZipPhoneEmployment Verification Yes No Job Title and DutiesSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for LeavingSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for Leaving EducationHigh SchoolName and Location of School (Location should be name of City, State, Zip)From Date To Date Graduate? Yes No College or UniversityName and Location of School (Location should be name of City, State, Zip)From Date To Date List Professional Licenses or CredentialsEducation Verification Yes No References List below the names of four persons not related to you whom you have known at least one year: Reference 1Name*Phone*AddressPersonal References Yes Reference 2Name*Phone*AddressPersonal References Yes Reference 3Name*Phone*AddressPersonal References Yes Emergency ContactName*Relationship to the Applicant*Phone Number*Email Address* Address* Street Address City State / Province / Region ZIP / Postal Code Previous EmploymentCompany NameAddress Street Address City State / Province / Region ZIP / Postal Code PhoneSupervisorFrom Date To Date Reason for leavingBy Signing this document below in order to obtain employment with Alliance Home Health Care, Inc., I hereby authorize you to supply the information requested below. I waive any possible claim against you or your organization and agree to release you from any liability regarding the provision of such information. I Agree Applicant Name*Position Applied ForAddress Street Address City State / Province / Region ZIP / Postal Code Applicant SignatureYour NameYour NameYour NameYour Name
