Application Form - AdvisaCare

Personal

Date

Name (first, middle, last)

Address

City

State

Zip Code

Phone

Email

How did you hear about us?

[group specify-referred]
Please specify:

[/group]

Position of interest

Date available to start work

Type of work
Full TimePart TimeOn Call

Shift preference

Days of the week available to work
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Professional discipline/title

Specialty

CPR certified?
YesNo

[group group-cpr-date]
Expiration date

[/group]

Licenses

State

License #

Expiration date

Add another license

[group group-license-2]
State

License #

Expiration date

Add another license

[/group]

[group group-license-3]
State

License #

Expiration date

[/group]

Certification

CertifiedRegisteredRegistry EligibleOther

[group group-certification-other]
Please specify

[/group]

Certificate, registration #

Expiration date

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?
YesNo

Have you ever been convicted of a crime or are any felony charges pending against you?
YesNo

Have you ever been named a defendant in a professional liability action?
YesNo

Have you previously applied or worked for AdvisaCare?
YesNo

Can you submit verification of your legal right to work in the United States?
YesNo

Would you travel, if necessary?
YesNo

Do you have reliable transportation?
YesNo

What type of cases have you enjoyed working on the most?

Educational History

High School

Name

Location

Diploma/degree received

College

Name

Location

Diploma/degree received

Graduate School

Name

Location

Diploma/degree received

Other

Name

Location

Diploma/degree received

Employment History

Are you currently employed?
YesNo

[group group-contact-employer]
May we contact your present employer?
YesNo

[/group]

Please provide the information below starting from most recent.

Name of employer

Dates employed

Reason for leaving

Last position held

Supervisor name & title

Pay rate beginning

Pay rate ending

Responsibilities

Add another position

[group group-employment-2]
Name of employer

Dates employed

Reason for leaving

Last position held

Supervisor name & title

Pay rate beginning

Pay rate ending

Responsibilities

Add another position

[/group]

[group group-employment-3]
Name of employer

Dates employed

Reason for leaving

Last position held

Supervisor name & title

Pay rate beginning

Pay rate ending

Responsibilities

Add another position

[/group]

[group group-employment-4]
Name of employer

Dates employed

Reason for leaving

Last position held

Supervisor name & title

Pay rate beginning

Pay rate ending

Responsibilities

Add another position

[/group]

[group group-employment-5]
Name of employer

Dates employed

Reason for leaving

Last position held

Supervisor name & title

Pay rate beginning

Pay rate ending

Responsibilities

[/group]

Describe your previous home care experience (i.e. Brain Injury, Spinal Cord Injury Medicare, Hospice, Worker’s Comp.)

Please list four (4) professional references
Name

Title

Email

Phone

Name

Title

Email

Phone

Name

Title

Email

Phone

Name

Title

Email

Phone

Employee agreement

● 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.
● I understand that this employment application and any other company documents 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.
● 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 guarantee me any fixed number of hours of work in any given time period.
● I authorize the release of all records pertaining to my education, work history and medical history to AdvisaCare.
● 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.
● I consent to drug and/or alcohol testing at the discretion of AdvisaCare
● I authorize AdvisaCare to seek and obtain any and all information concerning my previous work and employment history from all my previous employers.
● 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.
● 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.
● 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.
Applicant signature

Date

Personal

Licenses

Certification

Educational History

High School

College

Graduate School

Other

Employment History

Please provide the information below starting from most recent.

Please list four (4) professional references Name Title Email Phone Name Title Email Phone Name Title Email Phone Name Title Email Phone

Employee agreement

Please list four (4) professional references
Name

Title

Email

Phone

Name

Title

Email

Phone

Name

Title

Email

Phone

Name

Title

Email

Phone