Date
Name (first, middle, last)
Address
City
State
Zip Code
Phone
Email
How did you hear about us? ---GoogleFacebookJob boardBillboardWalk-inReferralOther
Position of interest
Date available to start work
Type of work Full TimePart TimeOn Call
Shift preference ---FirstSecondThird
Days of the week available to work MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Professional discipline/title
Specialty
CPR certified? YesNo
License #
Expiration date
Add another license
CertifiedRegisteredRegistry EligibleOther
Certificate, registration #
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?
Name
Location
Diploma/degree received
Are you currently employed? YesNo
Name of employer
Dates employed
Reason for leaving
Last position held
Supervisor name & title
Pay rate beginning
Pay rate ending
Responsibilities
Add another position
Describe your previous home care experience (i.e. Brain Injury, Spinal Cord Injury Medicare, Hospice, Worker’s Comp.)
Title
● 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
