RN - LPN Application

HIGH STANDARD HOME CARE, INC

EMPLOYMENT APPLICATION

This application must be completed and all questions regarding your training and work experience answered. All information on this application is confidential. High Standard Home Care, Inc. will not contact your present employer without your consent.
Name:*
Other Name: (if applicable)
Social Security #*
Sex*
Date of Birth*

MonthDayYear
Place of Birth*
Address*
Phone Number*
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Are you a US citizen?*

YesNo
Immigrant ID / Card:*
On what position do you wanna apply for?*

RNLPN

Education/Schools Attended

Work History

	Name and Phone # of Current/Former Employers	From: Mo/Yr	To: Mo/Yr	Job Title	Supervisor’s Name	Salary	Reason for leaving
1
2
3
4

Additional Reference

Have you ever been bonded?*

YesNo
By Whom:*
Have you ever been refused a bond?*

YesNo
By Whom:*
Have you ever been convicted of a crime?*

YesNo
Please explain:*
Have you ever “clocked in and out” before:*

YesNo
Please list all of the systems used:*
Have you ever been terminated from a position due to a conflict report:*

YesNo
Please specify further:*
Professional Licenses:*

Profession:Lic, No:
Exp. Date:*

MonthDayYear
Date
Para-Professional Certification:
The information listed in my application is complete and true.

I understand that if employed, false statements on this application are cause for dismissal.

I will comply with all of the agency’s rules and regulations regarding my employment.

High Standard Home Care, Inc may request information regarding my background which will include work and personal references.
Signature*

Clear
Date*

MonthDayYear
Date
High Standard Home Care, Inc. does not discriminate because of sex, age, physical handicap, race, creed or national origin. The agency is an equal opportunity employer.
Should be Empty:

HIGH STANDARD HOME CARE, INC