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We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin or marital status.

Please use your tab key as you fill out this application, after you push Enter this application will be submitted.

Personal
Date of Application:
Full Name (First, Middle, Last):
Social Security Number:
Current Address:
Address:
City:
State:
Zip:

Home Phone:
Business Phone:
Email Address
How did you hear about us?
 
Referral:
Other:
Position Applied For:
Date Available to begin working:
Are you available to work:
Full Time
Part Time
On-Call
Shift Preference:
First
Second
Third
Days you are willing to work:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Professional Discipline/Title
Specialty:
Are you currently CPR Certified?
Yes
No
Expiration Date:

Licensure:
State:
License #:
Expiration Date:



State:
License #:
Expiration Date:



State:
License #:
Expiration Date:

Certification:
Check one:
Certified

Registered

Registry Eligible

Other
Certificate, Registration / Registration Number:
Expiration Date:

Yes No
Have you ever had any Professional License or Certification placed under investigation, disciplined, suspended, revoked, put on probation or are there any restrictions placed on your License / Certification?


Yes No
Have you ever been convicted of a crime or are any felony charges pending against you?


Yes No
Have you ever been named defendant in a professional liability action?


Yes No
Have you previously applied or worked for AdvisaCare?


Yes No
Can you submit verification of your legal right to work in the United States?


Yes No
Can you perform the essential duties of the job in which you wish to be employed, with or without accommodation?


Yes No
Would you travel, if necessary?


Yes No
Do you have reliable transportation? What type?


Yes No
Do you have any experience working in a Nursing Home?

Person to notify in case of an emergency:
Name:
Address:
City:
State:
Zip:
Day Time Phone:
Evening Phone Number:

Educational History
Education
Name & Location of School
Diplomas, Degrees Received
High School
Name:    
Location:

College
Name:    
Location:

Graduate School
Name:    
Location:

Other School
Name:    
Location:

Employment History
Are you currently employed?
Yes
No
If so, may we contact your present employer?
Yes
No

Dates Employed:
From:

To:
Reason for leaving?
Facility / Employer:
Department:
Address:
City:
State:
Zip:
Position Held:
Supervisor's Name & Title:
Pay Rate Beginning:
Pay Rate Ending:
Responsibilities:

Dates Employed:
From:

To:
Reason for leaving?
Facility / Employer:
Department:
Address:
City:
State:
Zip:
Position Held:
Supervisor's Name & Title:
Pay Rate Beginning:
Pay Rate Ending:
Responsibilities:

Dates Employed:
From:

To:
Reason for leaving?
Facility / Employer:
Department:
Address:
City:
State:
Zip:
Position Held:
Supervisor's Name & Title:
Pay Rate Beginning:
Pay Rate Ending:
Responsibilities:

Please list any facilities where you have especially enjoyed working:
1.
2.
3.
4.
5.

Please list four (4) Professional References:
Name / Title
Address
Phone Number
1.


2.


3.


4.



Please list four (4) Personal References:
Name / Title
Address
Phone Number
1.


2.


3.


4.



Employee Agreement - Field Staff
  1. I certify the information stated on my application for employment is true and complete. I understand that any false statement or omission on the application or attachments may result in refusal of employment or immediate termination from AdvisaCare.
  2. I understand that this employment application and any other company documnets are not contracts of employment, express or implied, and that if hired, any employment with AdvisaCare is considered to be "at will" employment and may be terminated for any reason or cause: with or without notice.
  3. I understand that I may express preference for certain hours, days, or facilities for employment assignment, but these preferences may limit AdvisaCare's ability to offer assignments. I also understand that I may accept or decline assignments offered, and that, in any event, AdvisaCare does not guarentee me any fixed number of hours of work in any given time period.
  4. I authorize the release of all records pertaining to my education, work history and medical history to AdvisaCare.
  5. I authorize the release of background information obtained through a criminal record check to AdvisaCare as a voluntary pre-employment screening to assure the safety and security of their clients and employees.
  6. I consent to drug and/or alcohol testing at the discretion of AdvisaCare
  7. I authorize AdvisaCare to seek and obtain any and all information concerning my previous work and employment history from all my previous employers.
  8. I agree to maintain confidentiality regarding the affairs of AdvisaCare and its clients, including general business, names, addresses, and phone numbers of field staff and clients, anticipated changes in staff or management, or company pricing. I agree to maintain confidentiality regarding the identity, personal affairs, or medical status of facility patients or about the services provided to them.
  9. I understand I am prohibited from becoming employed by, or receiving compensation from, any client of AdvisaCare if i was assigned to provide services there by AdvisaCare within six (6) months of accepting the offer of employment or compensation. I further understand that failure to abide by this policy will result in my responsibility for payment of a fee to AdvisaCare or liquidation damages. This fee will be $8,500 if I am a Nurse or Therapist, and $5,000 if I am an Aide or Medical Assistant.
  10. I understand I must complete required OSHA training on Blood Borne Pathogens and the procedure to follow if I experience an occupational exposure, including the method of reporting the incident and the medical follow-up that will be made available prior to starting clinical shifts.


By signing below, I acknowledge that I have read and agreed to the above-mentioned items.

Employee Signature:
Date:
Social Security Number: