Caregivers Application Form

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Required Documentation for Employment

  1. Level II FDLE/FBI background check with electronic figerprints
  2. Nursing a License or HHA Certificate
  3. CPR certificate
  4. Physical and TB screening
  5. Social Security Card
  6. Drivers License
  7. Auto Registration and Insurance
  8. Direct Deposit account
  9. Copies of CEUs
  10. Business References

Employment Application

Please answer each question in a complete and accurate manner as no action will be taken on this application until all questions have been answered, attach your resume, then click submit. Required fields are indicated by a ( * ).

Our company is an equal opportunity employer and will consider all applicants for all positions equally without regard to race, sex, color, religion, national origin, veteran status, genetic information or any disability as defined by the Americans with Disabilities Act, or for any reason protected by State of Federal law. I understand that drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for immediate termination.

  • Personal Information

  • CNA, RN, LPN license number
    This is a 24 hour by 7 day a week business, please be specific.
  • Must speak fluent English

  • Education

  • Please include city and state or country.
  • School where you obtained any technical training for positions such as HHA or CNA.
  • Please any technical training or skills that may qualify you for a job with us.
  • Please describe why you are interested in working for Partners in Healthcare and list the skills and abilities that you feel particularly qualify you for a position with us.

  • Capability/Reliability

    Please complete all Questions

  • Employment History

    Do not reference your resume.

  • Personal References

  • Provide 3 references that are not relatives or former employers

  • Certification and Release

  • CERTIFICATION AND RELEASE: I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice and the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities, from any liability for any damage whatsoever for issuing this information. I further understand that the healthcare provider cannot provide a copy of this criminal history record check.
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