Acappella In Home Care Application

Personal Data Email Address:
First Name: Last Name: Middle Name:    
Home Address: City: State Zip  
Home Phone - - Cell Phone - - D.O.B.  -  -
 
Emergency Contact Information
Name of Emergency Contact Relation Emergency Telephone Number - -
 
Job Information
Position (Job Class) Applying for:
RN   PT  LP/VN   CNA OT PTA Clerical Other Date Available:
Work Experience/Skills
Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:
   Burn    ENT    Pediatrics    Detox/Drug Rehab
   L & D    Rehab    Telemetry    Post Partum
   MICU    Nursery    Psychiatry    Orthopedics
   NICU    Dialysis    Stepdown    Mother/Baby
   PACU    Geriatric    Oncology    Recovery Room
   SICU    Pedi ICU    Neurology    Operating Room
   CCU    Med/Surg    Open Heart    Emergency Room
   Other
    		   Other
    		   Other
    		   Other
   
 

Previous Facility Types Worked:  Check All That Apply –
Hospital    Hospice   Nursing Home Rehab Private Duty Assisted Living / Residential Treatment

Language Skills:   Other than English, please check any other languages
you speak –

Check the type of assignment you are available for:
Spanish    French   German Other:
Full-time    Part-time   Contract Travel

Check the days of the week you are available to work:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Days Nights Weekends Holidays available to work:
License Type License/Certification # State Expiration Date
License Type License/Certification # State Expiration Date
License Type License/Certification # State Expiration Date
 

Has your professional license ever been suspended, revoked or under investigation?  
Yes No
   If Yes, Please explain:  
Certifications:   Check all applicable certifications and enter expiration date:
ACLS Expiration Date:
BCLS Expiration Date:
CPR Expiration Date:
PALS Expiration Date:
Other Expiration Date:
 IV Expiration Date:
 NALS Expiration Date:

Work Experience:   List all of your work experience beginning with your most recent job.  You will be asked to explain all gaps in employment.  Attach additional sheet(s) if necessary.
Facility/Employer Name : Date Employed From: To:
Address  : Title :
City/State/Zip : Country : Unit :
Number of Beds in Unit: In Hospital: Name of Current Immediate Supervisor :
Describe duties and specialty areas: Telephone #:  
Pay Rate/Salary:   Hourly :   Yearly : May We Contact:
Yes  No – How often?
Reason for leaving:   If this was a travel assignment, name of agency:
Are your employment records listed under another name?
No  Yes - If yes, what name?   		Supervisory Experience:
Yes  No – How often?

 

Facility/Employer Name : Date Employed From: To:
Address  : Title :
City/State/Zip : Country : Unit :
Number of Beds in Unit: In Hospital: Name of Current Immediate Supervisor :
Describe duties and specialty areas: Telephone #:  
Pay Rate/Salary:   Hourly :   Yearly : May We Contact:
Yes  No – How often?
Reason for leaving:   If this was a travel assignment, name of agency:
Are your employment records listed under another name?
No  Yes - If yes, what name?   		Supervisory Experience:
Yes  No – How often?


Facility/Employer Name : Date Employed From: To:
Address  : Title :
City/State/Zip : Country : Unit :
Number of Beds in Unit: In Hospital: Name of Current Immediate Supervisor :
Describe duties and specialty areas: Telephone #:  
Pay Rate/Salary:   Hourly :   Yearly : May We Contact:
Yes  No – How often?
Reason for leaving:   If this was a travel assignment, name of agency:
Are your employment records listed under another name?
No  Yes - If yes, what name?   		Supervisory Experience:
Yes  No – How often?

 

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.
 

Additional Information:
1. Are you legally authorized to work in the USA?
Yes No
2. Have you ever been convicted of a felony? 
Yes No
3. Can you pass a pre-employment drug test?  
Yes No
4. How were you referred to Acappella In Home Care?
Yes No
Newspaper Trade Publication Job Fair/Open House Internet Site Company Employee – Name:
 

 

I understand that I must report all accidents to my immediate supervisor and to Acappella In Home Care - - No MATTER HOW SLIGHT.   Yes

I also understand that I must wear all required personal protection equipment (PPE).      Yes

The penalty for not wearing PPE is disciplinary action, up to and including termination.



Signature

ACKNOWLEDGMENT  (Please read carefully and sign)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete.  I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.


I give Acappella In Home Care permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Acappella In Home Care with regard to any of the subjects covered by this application.  I also understand that in connection with my application for employment or my employment, Acappella In Home Care may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation.  I release Acappella In Home Care, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.


In consideration of my employment and of my being considered for employment by Acappella In Home Care, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice.  I also understand that if employed, I will be an employee at will and employed for no definite period of time.  I understand that either Acappella In Home Care or I can terminate my employment at any time, with or without cause and with or without advance notice.  I further understand that no communication, whether oral or written, by any representative of Acappella In Home Care, at any time, can constitute a contract of employment.  No representative or agent of Acappella In Home Care, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.


I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws.  If I receive an offer of employment I agree that my continued employment may be contingent on the results.


I understand that Acappella In Home Care is not involved in the day-to-day supervision or decision concerning patient care or dentistry.  This remains with the Professional as part of the Professional’s practice.  The Professional fully indemnifies Acappella In Home Care against any and all liability and responsibility associated with his or her professional duties.  The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

 

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

 

Applicant Signature   Date :