Name (last, first, middle)*
Street Address*
City* State* Zip*
Home Phone Number*
May We Contact You at Work* Yes No Work Phone Number*
Best Time to Call* Email Address

Have You Ever Been Employed, Licensed, Certified or Received a Degree Under a Different Name?
Yes No

Are you a citizen or otherwise legally able to work in the U.S.? Yes No
(Proof of citizenship/immigration status will be required upon employment).

Are you related to any employees of No Greater Love Home Health Care? Yes No
If Yes, please indicate name and relationship

Have you ever applied or worked at this organization before? Yes No
If Yes, position
Reason for leaving

How did you learn of No Greater Love Home Health Care?
Employee Relative Friend Patient Newspaper Ad,
please indicate name of newspaper

Have you ever pled guilty to, been convicted of, or are presently charged with any violation of the law, other than a traffic or speeding violation? Yes No
If Yes, please explain. (Answering Yes Does Not Automatically Disqualify You For Consideration For Employment).

Are you currently serving probation, conditional discharge or pretrial diversion for any crime?
Yes No
If Yes, provide details on offense, disposition and current status

Position Desired

Position(s) for which you are applying

Date available for employment
Salary Desired
(Please check all applicable boxes)
Employment Desired
Full Time Part Time Per Diem Per Visit On Call
Shift Preference
Day Evening Night Other

Education and Training

Please list all schools attended

Please indicate all other training that may be relevant to your application

Skills

List any additional qualifications or skills you have for the position for which you have applied

List any languages in addition to English you can speak

Write
Read

Describe your computer skills

Describe office skills, business machine training and experience

Licensure/Certification

If required, do you hold a valid license/certification/registration for the position for which you have applied? Yes No
If yes, please state license/certification/registration number

Expiration date

Have you ever been denied a professional or occupational license, certification or registration? Yes No
If yes, provide issuing state(s), type of license/certification/registration and numbers

Has any license, certification or registration that you hold/held ever been investigated, revoked, suspended, limited or subject to discipline by any board or governing authority? Yes No
If yes, provide issuing state(s), type of license/certification/registration and numbers and please explain in detail

Have you ever been denied professional liability insurance or had such a policy cancelled? Yes No
Have you ever been named as a defendant in a professional liability claim? Yes No
If yes to either question, please explain in detail

Do you hold a valid driver's license? Yes No

Do you have an automobile insurance policy in effect? Yes No
(A certificate of insurance naming No Greater Love Home Health Care as a certificate holder is required at the time of employment)

Employment History

Please provide employment information for the prior ten years or your four prior employers, whichever is greater. Explain all periods of unemployment. Please begin with your current or most recent employer. References will be required before employment.

Employer
(Current or most recent employer)
May we contact? Yes No
Street Address
Phone Number
City State Zip
Salary
Worked There From To
Position Held Supervisor
Reason For Leaving

Employer
May we contact? Yes No
Street Address
Phone Number
City State Zip
Salary
Worked There From To
Position Held Supervisor
Reason For Leaving

Employer
May we contact? Yes No
Street Address
Phone Number
City State Zip
Salary
Worked There From To
Position Held Supervisor
Reason For Leaving

Employer
May we contact? Yes No
Street Address
Phone Number
City State Zip
Salary
Worked There From To
Position Held Supervisor
Reason For Leaving

Employer
May we contact? Yes No
Street Address
Phone Number
City State Zip
Salary
Worked There From To
Position Held Supervisor
Reason For Leaving

Employer
May we contact? Yes No
Street Address
Phone Number
City State Zip
Salary
Worked There From To
Position Held Supervisor
Reason For Leaving

Personal References

Please list the names of three individuals whom you have known for at least two years. No employers or relatives.

Name
Years Known
Street Address
Phone Number
City State Zip
Relationship (Friend, Pastor, Teacher, etc.)

Name
Years Known
Street Address
Phone Number
City State Zip
Relationship (Friend, Pastor, Teacher, etc.)

Name
Years Known
Street Address
Phone Number
City State Zip
Relationship (Friend, Pastor, Teacher, etc.)

Applicant's Certification and Agreement

Please Read Carefully

I verify that all the information which I have provided on this application and in any resumes and exhibits are true, correct and complete. I understand that any false, misleading, incomplete or omitted information will result in rejection of my application or dismissal from employment, whenever discovered. If my application is considered for employment, I authorize No Greater Love Home Health Care to conduct an investigation of my suitability for employment and to obtain verification of information that I provided on this application, resumes and exhibits. I authorize such information to be used for any decisions related to my hiring and continued employment. No Greater Love Home Health Care will conduct a background and reference check on candidates offered positions of employment.

I understand that this application is not a job offer. If hired, I understand that the first one hundred twenty (120) days of employment at No Greater Love Home Health Care will be considered as a period of adaptation and employment may be terminated during this period by either the employee and/or the employer with no eligibility for benefits or termination pay. My employment is not for a stated period of time and I may resign or be terminated with or without cause at any time, at the option of either myself or No Greater Love Home Health Care. I understand that I may be working in one or all subsidiaries of No Greater Love Home Health Care and that my shift or schedule may vary.

Employment is subject to completion of pre-employment procedures, including but not limited to, verifying employment and personal references, as appropriate criminal background check and driving record, and verification of licensure, certification or registration. In addition, if hired, applicants must complete a Federal I-9 form and provide verifiable documentation of their legal right to reside and work in the United States. I also understand that offer of employment is contingent upon passing a pre-placement physical exam and health screening and may require a drug testing.

If employed, I will comply with all policies, procedures and work rules. In the event that I am photographed or interviewed during the course of my employment, No Greater Love Home Health Care has my permission to use any and all materials gathered.

Please indicate your acceptance of the terms of this application
Yes No