Application

Premier Home Health Care
APPLICATION FOR EMPLOYMENT
Applicant Note: Premier Home Health Care is an equal opportunity employer. All qualified applicants will receive consideration for employment without discrimination because of sex, marital status, race, age, creed, national origin or the presence of disability. If you need help to fill out this application form or for any phase of the employment process, please notify the person that gave you this form, and every effort will be made to accommodate your needs in a reasonable amount of time. Additional testing of job-related skills may be required prior to employment. All facts, records, and information obtained will be held in the strictest confidence.

Please complete all pages. When you finish a page, click "next". When you reach the last page you will need to click "submit/finish" otherwise the application will not be sent.

Thank you!
Name *

First Name Middle Name Last Name Suffix
Email
example@example.com
Address *
Telephone Number *
SS# *
Are you either a U.S. citizen or an alien authorized to work in the U.S.? *

Yes No
Have you ever plead guilty to, received a suspended imposition of sentence ("SIS") for, or been convicted of a misdemeanor or felony? (A guilty plea, SIS, or conviction record will not automatically disqualify you from consideration. Such factors as the length of time since the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.) *

Yes No
if yes, please explain:
Office Location *
Position Applied For *
How were you referred to Premier Home Health Care?
I am fluent in the following languages
How many hours do you wish to work? *

AVAILABILITY *

AVAILABLE TIMES

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

SUNDAY

I can work (check all that apply):

Holidays NO Holidays Weekends NO Weekends Overtime NO Overtime Overnights NO Overnights PRN NO PRN
Date you are available to start working: *

Month Day Year
Date

License / Certificate - Please only list current/valid licenses and certificates.

Type/Description

State

Number

Expiration

Driver's License

Professional

Other

Education

School Name

Location

Degree/Major

Graduated Y/N

Year Graduated

Entry 1

Entry 2

Entry 3

TO BE COMPLETED BY APPLICANT

Please complete the following 2 reference cards using information about your most recent employers.
Applicant Name
Social Security Number
Previous Employer
Address
Phone
Approximate # Hrs Per Week
Start Date
End Date
Position(s) Held
Wage Rate
Reason for Leaving
I hereby authorize you to disclose all and any information concerning my employment with your firm to Premier Home Health Care. I understand this is in accordance with all applicable Federal and State laws.
Signature of Applicant

Clear
Date

Month Day Year
Date
WE ARE AN EQUAL OPPORTUNITY EMPLOYER

TO BE COMPLETED BY APPLICANT

Please complete the following 2 reference cards using information about your most recent employers.
Applicant Name
Social Security Number
Previous Employer
Address
Phone
Start Date
Start Date
Approximate # Hrs Per Week
Position(s) Held
Wage Rate
Reason for Leaving
I hereby authorize you to disclose all and any information concerning my employment with your firm to Premier Home Health Care. I understand this is in accordance with all applicable Federal and State laws.
Signature of Applicant

Clear
Date

Month Day Year
Date
WE ARE AN EQUAL OPPORTUNITY EMPLOYER

We appreciate your time and effort in completing this application. If you would like to go ahead and include your credentials, you may do so below.

Thank you!

Premier Home Health Care
Hiring Team
Take Photo
Should be Empty:

Premier Home Health Care

APPLICATION FOR EMPLOYMENT

PERSONAL REFERENCES (NO FAMILY)

Personal Reference 1

Personal Reference 2

Personal Reference 3

TO BE COMPLETED BY APPLICANT

TO BE COMPLETED BY APPLICANT