Employment Application |
|
FirstCare Home Health 3901 Normal Blvd - Ste 102 Lincoln, NE 68506 402-435-1122 Application for Employment
|
Position(s) Applying For: (please check all that apply)
|
Certified HHA/CNA(75hr)
LPN
RN
|
Physical Therapist
OT/ST
Home Care
|
Part-Time
Full-Time
Other/Specify
|
|
Clinical Applicants |
|
License Type |
Date of Expiration |
State |
Number |
|
|
|
|
|
|
|
|
|
|
|
|
|
Last Name: First Name: Middle: |
|
Address: City: State: Zip: |
|
Phone Number(s): |
|
Email: |
|
List best times to call: |
|
Have you ever filed an application here before? |
Yes No If yes, give date |
Have you ever been employed by FirstCare before? |
Yes No If yes, give date |
Are you able to perform the tasks this job requires? |
Yes No If no, please explain |
Are you eligible for employment in this country? |
Yes No |
Have you ever had a criminal conviction? |
Yes No If yes, please explain |
Are you on a lay-off and subject to recall? |
Yes No |
Will you travel if job requires it? |
Yes No |
Can you meet the attendance requirements? |
Yes No |
Are you willing to work overtime? |
Yes No |
Have you ever been bonded? |
Yes No |
Are you CPR Certified? |
Yes No If yes, where and when |
Do you speak any foreign languages? |
Yes No If yes, please specify |
Do you have a reliable automobile? |
Yes No |
Do you have automobile insurance? |
Yes No If yes, give date |
|
Employment History |
|
Please list your last four(4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments below. |
|
Employer Telephone Begin date End Date |
Address Starting Hourly Rate/Salary Final Hourly Rate/Salary |
Immediate Supervisor and Title Job Title |
Summarize the nature of the work performed and job responsibility |
|
Reason(s) for Leaving |
|
May we contact for a reference? Yes No |
|
|
Employer Telephone Begin date End Date |
Address Starting Hourly Rate/Salary Final Hourly Rate/Salary |
Immediate Supervisor and Title Job Title |
Summarize the nature of the work performed and job responsibility |
|
Reason(s) for Leaving |
|
May we contact for a reference? Yes No |
|
|
Employer Telephone Begin date End Date |
Address Starting Hourly Rate/Salary Final Hourly Rate/Salary |
Immediate Supervisor and Title Job Title |
Summarize the nature of the work performed and job responsibility |
|
Reason(s) for Leaving |
|
May we contact for a reference? Yes No |
|
|
Employer Telephone Begin date End Date |
Address Starting Hourly Rate/Salary Final Hourly Rate/Salary |
Immediate Supervisor and Title Job Title |
Summarize the nature of the work performed and job responsibility |
|
Reason(s) for Leaving |
|
May we contact for a reference? Yes No |
|
Educational Background |
|
List the three (3) schools attended, starting with the last one first. List the number of years completed. Indicate degree or diploma earned, if any. List your Grade Point Average or Class Rank. Finally list your Major and Minor fields of study (if applicable). |
|
|
|
References |
List name and telephone number of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. |
|
Name |
Telephone Number |
Years Known |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
List professional, trade, business or civic associations and any offices. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status) |
|
Organization |
Offices Held |
|
|
|
|
|
|
|
|
List special accomplishments, publications, awards. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status) |
|
|
|
List any additional comments or information you would like us to consider, including special skills and qualifications acquired from employment or other experiences that may qualify you to work with our company. |
|
|
|
How did you hear about FirstCare? |
|
|
Days and Hours available for assignments: |
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday |
|
Are you fluent in sign language? Yes No |
|
Are you fluent in any foreign language? Yes No If Yes, please list: |
|
It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed.
I give the Employer the right to investigate all references and to secure the additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.
The Employer is an Equal Opportunity Employer, the Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.
This application is current for only sixty (60) days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.
I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.
By clicking Send Application, you acknowledge everything is correct.
|
|