HomeNurse Online Employment Application (Step 1 of 4)

 
HomeNurse, Inc. is committed to being an equal opportunity employer for all employee and job applicants. It is our policy to grant equal employment opportunity to all qualified persons without regard to race, sex, religion, age, national origin, physical or mental disability and any other status protected by federal, state or local laws.
 

Please answer all of the questions, sign the form with your mouse in the area provided at the bottom of the form and press the Submit Application button. Fields in BLUE are required. This is a secure form so your personal information is safe.

Personal Information

First Name: Middle: Last:
Address:
City: State: Zip:
County: Phone:
Email:
SSN:
(XXX-XX-XXXX)
Retype SSN:
(XXX-XX-XXXX)




 
Employment Questionaire

Position
Applied For:
If Other Position: License No:
If applying for an LPN or RN position,
please supply your current license number

Do you have use of an automobile?
 
Are you 21 years or older?
 
Have you ever served or are you currently serving in the military?
 
Do you have the legal right to work in the United States?
(Note: Proof of identity and legal authority to work
in the United States is a condition of employment.)

 
Have you ever been convicted of a felony?


If yes, please describe:
 
Have you ever worked for HomeNurse before?


If yes, when?
 
Are you experienced with the use of a Hoyer Lift?
 
What language(s) do you speak? (Check as many as apply)





 
 
How did you hear about us?
Referred by
Compensation requested
Briefly describe any skills you have acquired in previous employment or military service
 
Availability

Date you are available to start work:
What days/hours are you available to work? (please check all that apply).









Please tell us if you are going to work another job or go to school if employed by HomeNurse:
(Please check all that apply and describe your schedule).
    
From:  To:    From:  To: 
From:  To:    From:  To: 
From:  To:    From:  To: 
From:  To:    From:  To: 
From:  To:    From:  To: 
From:  To:    From:  To: 
From:  To:    From:  To: 
 
Education

Name & Location of School Grade Completed/
Years Attended
Did You Graduate? Subjects Studied/Degree Earned
High School
College
Technical/Vocational School
 
Employment History

Please list current/previous employers for the last five(5) years starting with the most recent. A complete five(5) year work history is required.
Employer:
Address/City:
From:
To:  (Leave blank if you are currently employed here)
Supervisor:
Phone:
Salary:
Type of Work/Position:
Reason for Leaving:
 
Employer:
Address/City:
From:
To:
Supervisor: Phone:
Salary:
Type of Work/Position:
Reason for Leaving:
 
Employer:
Address/City:
From:
To:
Supervisor: Phone:
Salary:
Type of Work/Position:
Reason for Leaving:
 
Employer:
Address/City:
From:
To:
Supervisor: Phone:
Salary:
Type of Work/Position:
Reason for Leaving:
 
Please list and describe any gaps in your work history above
From To Reason












 
List any person or person’s whom you have provided in-home care for including family members:
 
References

Give The Names of Three Persons Not Related To You, Whom You Have Known At Least One Year
Reference Full Name Address and Phone Number Occupation Years Acquainted
 
Emergency Contacts

Give The Names, Relationships, and Phone Number of at least one individual that we should contact in the event of an emergency.
Emergency Contact Full Name Relationship Phone Number



 

Please read carefully before submitting your application

Information about a patient/client’s condition, care, treatment, personal affairs, or records is confidential and may not be disclosed with anyone except your supervisor and/or those responsible for the patient/client care and treatment, without the full consent of the patient/client or when compelled by legal requirements. You will safe-guard confidence as a trust and reveal such confidence only after careful deliberation and when there is a clear and imminent danger to an individual or society. I agree that I have been informed of the requirements of the work for which I am applying, and that the information in this application is correct and complete to the best of my knowledge. I understand that is shall be grounds for immediate dismissal if any of the information contained herein is found to be untrue. I authorize you and all former employers, given by me as references, to answer all questions and to give all information contained in connection with this application or in anyway concerning me. I understand that if accepted for employment, I will be working for you on your payroll, at the client’s premises.

I agree that I will obtain your permission before discussing permanent employment with your client. I agree to immediately notify you at the conclusion of each assignment as soon as I become available. If I fail to give to give you such notice, you may assume that I am not available for reassignment, and am not ready, willing and able to work. Failure to do so is considered job abandonment and under current law, unemployment benefits can be denied. I understand that any information that I learn while working for a client is to be kept confidential. I agree, if employed, that if I ever make claims against you for personal injuries, upon request I shall submit to examinations by physicians of your choice. I will hold HomeNurse harmless from any claims including but not limited to person injuries or illness as a result of my providing false or misleading information on this application. I hereby acknowledge that my employment is at “will” and “temporary” , that I may resign at any time and the company may terminate my employment at any time, with or without reason, except that no employee will be discharged for reasons that are prohibited by state and federal laws.

I understand and agree that I have never been shown by credible evidence (i.e. court or jury, department investigation, or any reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct. I hereby authorize HomeNurse, Inc., by accepting these conditions, to receive criminal history information pertaining to me from any criminal justice agency in any state.

 
 
 

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