1 Application for Comprehensive Nursing Services, Inc.

Comprehensive Nursing Services, Inc.
Comprehensive Home Health Services
Please upload your resume here if you have not already submitted it. If you are unable to upload you may bring a copy with you the day of your interview. Thank you

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Application for Employment and Request for Background Information

Please Type or Print and Please Complete All Sections
Name*

First NameLast Name
Middle
Maiden Name
Date of Birth*

MonthDayYear
Date
Social Security Number (xxx-xx-xxxx)*
Home Address for Past 10 Years - Please List Current Address First

If more than 2 addresses in the last 10 years they can be completed during interview
Current Address*

Street Address

Apt or Unit Number - if applicable

CityState / Province

Postal / Zip Code
From Month*
Year (YYYY)*
To Month*
Year (YYYY)*
Previous Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From Month
Year (YYYY)
To Month
Year (YYYY)
Home Telephone
Email*
example@example.com
Mobile*
Professional License Number*
Employment Record

Please complete with your most current employer listed first
Name of Employer #1*
Current or Most Recent
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From (MM/YYYY)*
To (MM/YYYY)*
Employers Phone*
Supervisor
Description of Duties/Responsibilities*
Name of Employer #2*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor
From (MM/YYYY)*
To (MM/YYYY)*
Phone*
Description of Job/Duties*
Name of Employer #3
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor
From (MM/YYYY)
To (MM/YYYY)
Phone
Description of Job/Duties
References

Please list three (3) individuals with whom you have worked who were in a position to evaluate your performance.
1st Reference Name*

First NameLast Name
Company*
Title or Position Held*
Phone Number*
Please enter a valid phone number.
2nd Reference Name*

First NameLast Name
Company*
Title or Position Held*
Phone Number*
Please enter a valid phone number.
3rd Reference Name

First NameLast Name
Company
Title or Position Held
Phone Number
Please enter a valid phone number.
Education

Education - List Most Recent First
School Attended*
School Address, City, State & Zip*
Degree or Certificate Earned*
Month Started*
Year Started (YYYY)*
Month Completed*
Year Completed (YYYY)*
School Attended
School Address, City, State & Zip
Degree or Certificate Earned
Month Started (please choose from drop down list)
Year Started (YYYY)
Month Completed (please choose from drop down list)
Year Completed (YYYY)
School Attended
School Address, City, State & Zip
Degree or Certificate Earned
Month Started (please choose from drop down list)
Year Started (YYYY)
Month Completed (please choose from dropdown list)
Year Completed (YYYY)
General Information
Are you legally authorized to work in the USA?*

YesNo
Have you ever been convicted of a felony or misdemeanor or crime?*

YesNo
(This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.) A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its occurrence and any rehabilitation you have undergone. If YES, state the basis for each conviction and the date of the conviction
Are you able to perform the tasks according to the job description without accommodation?*

YesNo
If NO, and an accommodation is needed, how would you perform the task and with what accommodation?
Availability (check all that apply)

DaysNightsEveningsWeekends
If you checked Days, how many day hours?
If you checked Nights, how many night hours?
If you checked Evenings, how many evening hours?
If you checked Weekends, how many weekend hours?
Hours Desired:

Full TimePart Time
How did you learn of this opening? ex: Indeed, Monster, referred by, etc.*
If referred by, please type the person's name
Date you can start? Month MM* Day DD* Year YYYY*
Do you have any pediatric experience, anyone under the age of 19, in the last 3 years?*

YesNo
Did you serve in the Military?*

YesNo
If yes, Branch of Service
Separation Rank
Rank
Occupation
In Case of Emergency - Contact Information
Full Name - Emergency Contact 1*
Relationship*
Telephone*
Address
Full Name - Emergency Contact 2
Relationship
Telephone
Address
This institution does not discriminate in hiring or in any other decision on the bases of race, color, sex, citizenship, national origin, ancestry, Vietnam Era Veteran Status or on the bases of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three (3) days show satisfactory evidence of identity and eligibility for employment.

In connection with this request, I authorize all corporations, companies, credit agencies, educational institutions, persons, law enforcement agencies and former employers to release information they may have about me and release them from any liability and responsibility from doing so; further, I authorize the procurement of an investigative consumer report and understand that such report may contain information as to my background, mode of living, character and personal reputation. Further information may be available upon written request within a reasonable period of time.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Comprehensive Nursing Services, Inc. Comprehensive Home Health Services
Should be Empty:

Comprehensive Nursing Services, Inc.

Comprehensive Home Health Services

Employment Record

References

Education

General Information