Employment Application PERSONAL INFORMATION Name* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* PhoneAre you 18 years or older*YesNo DESIRED EMPLOYMENT Poistion you are applying for:*Registered NurseMedication TechnicianCertified Nursing Assistant (CNA)Home Health AideLicensed Practical Nurse (LPN)Desired SalaryStart Date* MM slash DD slash YYYY Are you currently employed?*YesNoMay we inquire of your current employer?*YesNoHave you ever worked for this company?*YesNoWho referred you to Blessing Home Healthcare? Friend Employee Advertisement Government Placement Agency Internet Other Specify CURRENT EMPLOYER Current EmployerTelephoneReason for leavingName of last supervisor EMPLOYMENT HISTORY Name of Employer 1List your last two (2) employers, assignments of volunteer activities, including experience. Explain any gap in employment in the comments section below.Job TitleAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code From* MM slash DD slash YYYY To* MM slash DD slash YYYY What was the nature of your work?*Hourly rateName of supervisorPhoneComments Name of Employer 2Job TitleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country From* MM slash DD slash YYYY To* MM slash DD slash YYYY What was the nature of your work?*Hourly rateName of supervisorPhoneCommentsARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?*YesNo(Proof of eligibility will be required before employment) EDUCATION High School Name of School & LocationNumber of years attendedDid you graduate?YesNoMajorCollege | University Name of School & LocationNumber of years attendedDid you graduate?YesNoMajorProfessional Training Name of School & LocationNumber of years attendedDid you graduate?YesNoProfessional Certification EMERGENCY CONTACT Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Relationship PERSONAL REFERENCES Professional Reference 1 - Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneBusinessFrom MM slash DD slash YYYY To MM slash DD slash YYYY Professional Reference 2 - Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneBusinessFrom MM slash DD slash YYYY To MM slash DD slash YYYY Have you been convicted of a crime in the last 5 years?*NoYesPlease explain (Will not necessarily prevent your employment)Please check the box* I certify that the facts contained in this application are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for a subsequent discipline up to and including dismissal from employment if discovered at the later date. I understand that if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Blessing Home Healthcare other than the owners is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owners. CERTIFICATION Check all that apply* Select All RN LPN GNA/CNA Other StatePlease list certificationSKILLS The following information will help us place you where your skills, knowledge of nursing and preferences will be best suitedCan you do vital signsYesNoCan you do nurses notes?YesNoCan you do catheter care?YesNoCan you insert catheters?YesNoCan you start IVs?YesNoDo you suction patientsYesNoCan you set up oxygen for patients?YesNoCan you do neurological Assessments?YesNoCan you give intramuscular medications?YesNoCan you give IV medications?YesNoCan you assess patients for admission?YesNoCan you discharge patients?YesNoHave you had CPR?YesNoDo you have intensive care experience?YesNoIn which of the following areas have you had experience??Med/SurgOB/GynOncologyEmergency RoomHave you had any special training in nursing? If so, what?PreferencesAre you a licensed driver?YesNoWill you travel 30 minutes one way?YesNoAre you a licensed driver?YesNoWill you work shifts at a hospital?YesNoWill you work shifts at a nursing home?YesNoWill you work private duty cases?YesNoPlease rate your physical condition.ExcellentGoodFairSelect the time of day you are availableMorningAfternoonEveningSelect your days of availability Monday Tuesday Wednesday Thursday Friday Saturday Sunday How many hours a week do you wish to work?Do you have any handicaps? If so, please describe: If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Blessing Home Heatlhcare Services. This application will remain on the active file for 60 days. If I am hired within this period, this form will be transferred to my individual personal file. If I am not hired or have not heard from this agency within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Blessing Home Heatlhcare Services. I do hereby give the employer and/or its agents, including consumer-reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but is not limited to, credit reports, criminal conviction records, motor vehicle driving records, and previous employment history. Further, I hereby release from liability and hold harmless Blessing Home Heatlhcare Services and, its representative, all persons and organizations/companies for furnishing such information. If required, I agree to a drug-testing prior to and during employment or for post-accident occurrences. The employer, Blessing Home Heatlhcare Services is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions 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. NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report, which includes information as to your character, general reputation, personal characteristics, and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.” Signature*Date MM slash DD slash YYYY Please attach photocopies of the following. Birth Certificate Drivers License Copy of Social Security card Employment Authorization/Eligibility CPR Certifications (if any) Professional License (if any) First Aid Certificate(if any) BLS Unrestricted professional Lic (if any) Criminal background check using CJIS # File Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 64 MB, Max. files: 5.
