Employment Application
* Indicates Mandatory Fields
Title
* First Name
Middle Name
* Last Name
*D.O.B
*Gender
*Address 1
Address 2
*Zip
*City
*State
*SSN
* Cell Phone
Home Phone
* Email Id
Languages
*Position Applying For:
*How Were You Referred:
Referred Person:
*Are you legally Eligible to be Employed in United States?
*Will you now or anytime in the future need to be sponsored for Employment Visa Status?
( Office Positions can skip this section )
Willing to provide service to a client with a pet?
Willing to provide service to a client who smokes?
Own reliable transportation?
Do you have a valid driver’s license?
DL No.:
DL. Expiry Date:
Preferred Day and Time
| Day | From | To |
|---|---|---|
| ( Office Positions can skip this section ) | ||
| Apply Time to All | ||
Certifications
| Certificate Name | Expiry Date | |||
|---|---|---|---|---|
| | ||||
| | ||||
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 Add More Certifications | ||||
Skills
Education
| Name | zip | City, State | Major / Subject | # Yrs Attended | Graduate | |
|---|---|---|---|---|---|---|
| High School | ||||||
| College/University | ||||||
| Vocational/Technical |
Previous Employment
| Previous Employment 1 |
| Employer May we Contact this Employer?:
Address Zip City State Job Title/Designation From To Supervisor Phone |
| Previous Employment 2 |
| Employer May we Contact this Employer?:
Address Zip City State Job Title/Designation From To Supervisor Phone |
*Clinical Reference
Clinical Reference #1
Name:
Company Name:
Company Phone:
Name/Title:
Date:
Clinical Reference #2
Name:
Company Name:
Company Phone:
Name/Title:
Date:
References
| Reference 1 |
| Name Address Zip City State Home Phone: Work Phone: Relation: Years known: |
| Reference 2 |
| Name Address Zip City State Home Phone: Work Phone: Relation: Years known: |
Comments
Statement of Employability
| 01 | *Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? |
| 02 | If yes, please explain. |
| 03 | *Please select the choice that accurately refects your Hepatitis B Vaccine status: |
| | |
| 04 | *Mycobacterium Tuberculosis is transmitted by air, carried in droplets that are created when a person with respiratory TB coughs, sneezes or shouts. TB Infection occurs when someone inhales the droplet particles containing the Mycobacterium. A person may have no symptoms, but still have latent TB infection (LTBI) and may develop TB disease at some point in their lives. TB skin tests may become positive in 2 to 12 weeks after the exposure. The following criteria is utilized to identify if an employee has potential TB. This criteria is also utilized to determine if an employee needs another chest xray. This information is also presented in training. Do you have any of the following Potential active symptoms of TB which include but limited to: Persistent cough greater than 2 weeks duration, Bloody sputum, Hoarseness, Fatigue, Chest pain, Night sweats, Weight loss, Anorexia, or Fever?
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| 05 | *Do you consider yourself part of any of the following groups that have a higher prevalence of TB infection? 1. Medically underserved populations 2. Homeless individuals 3. Current or past prison inmates 4. Alcoholics 5. Injecting drug users 6. Elderly 7. Foreignborn persons from Asia, Africa, the Caribbean and Latin America 8. Contacts to individuals with TB 9. Groups with a greater risk to progress from latent TB infection to active disease 10. Individuals with HIV infection, silicosis, SIP gastrectomy or jejunoileal bypass surgery, greater than 10 lb. Below normal body weight, chronic renal failure, diabetes mellitus, immunosuppressed due to medication, and those with some malignancies. 11. Individuals who have been infected within the past 2 years and individuals with fibrotic lung disease on chest xray.
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