Premier Home Health Care, Inc.

Step 1: Application of Employment
Application Note: PHHC is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without discrimination because of sex, marital status, race, age, creed, national origin, disability or veteran status. This application form is intended for use in evaluating your qualifications for employment. It is not an employment contract. Testing of job-related skills and a drug and alcohol screen will be required prior to employment. Depending on company policy or the needs of the position, an examination by a medical professional may be required.

Position Applied for:

Applicant's name:

Last:

First:

Middle:

Maiden Name or Other Names Known by:

Last:

First:

Middle:

Address:

City:

State:

Zip:

Email:

Telephone:

Social Security Number:

Are you either a US citizen or an alien authorized to work in the US?

yes

no

Have you ever applied at Premier Home Health?

yes

no

Have you ever been employed at Premier Home Health?

yes

no

Have you ever plead guilty to, received a suspended imposition of sentence (“SIS”) for, or been convicted of an ordinance violation, misdemeanor or felony?

yes

no

If yes, please explain (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.):

Education Information

Indicate the Highest level of Education Completed

Some High School:

High School:

Some College/University:

College/University:

Please give the name of the High School(s), College(s), and/or University(s) attended:

Please complete the information for any license or certificate you hold (ie, RN, LPN, CNA, etc.)

Type of License:

State of License:

Certificate/License #:

Expiration Date:

Drivers License Information
List last 3 employers beginning with the most recent. We will make every effort to contact previous employers; therefore the correct telephone numbers for past employers is critical.

Current or Last Employer:

Phone (Include area code):

Address:

City:

State:

Zip:

Named Used While Employed:

Job Title:

Salary:

Date worked from (mm/dd/yy):

Date worked from (mm/dd/yy):

Nature of Work:

Supervisor:

Reason for Leaving:

Previous Employer:

Phone (Include area code):

Address:

City:

State:

Zip:

Named Used While Employed:

Job Title:

Salary:

Date worked from (mm/dd/yy):

Date worked from (mm/dd/yy):

Nature of Work:

Supervisor:

Reason for Leaving:

Previous Employer:

Phone (Include area code):

Address:

City:

State:

Zip:

Named Used While Employed:

Job Title:

Salary:

Date worked from (mm/dd/yy):

Date worked from (mm/dd/yy):

Nature of Work:

Supervisor:

Reason for Leaving:

Personal References – Not Family Related

Name:

Address:

City:

State:

Zip:

Relationship (Friend, Minister, etc.):

Years Known:

Phone (Include Area code):

Name:

Address:

City:

State:

Zip:

Relationship (Friend, Minister, etc.):

Years Known:

Phone (Include Area code):

List other experience related to job applying for (paid or unpaid):

Additional Comments :

Step 2: How did you learn about this job (referral source)?

Newspaper

Television

Radio

Job Fair

Career Center

Employee Referral

Website

College/University

Flyer/Brochure

Step 3:
By checking the I Agree box next to the submit button of the online application, 1 (the applicant) agree that:

(1) I have read and understood the applicant note at the top of this form.
(2) The information given by me in this application is correct to the best of my knowledge.
(3) I understand that any false information, omissions or misrepresentations of facts called for in this application may result in the rejection of my application or discharge at any time during my employment.
(4) I authorize Premier Home Health Care and/or its agents to verify any of this information including, but not limited to, criminal history and motor vehicle records.
(5) I also authorize any reference source to provide Premier Home Health Care with any and all information covering my background and hereby release any sources from any liability for any damage whatsoever for issuing this information.
(6) I further agree that Premier Home Health Care may furnish like information to those with whom I may hereafter seek employment and hereby agree to save Premier Home Health Care free and harmless from any and all liability.
(7) I authorize and consent to Premier Home Health Care’s release of any and all information and records maintained by Premier Home Health Care as relates to my employment, including but not limited to, any federal or state agency conducting any investigation or audit of Premier Home Health Care or its employees, any investigation or audit regarding any client/patient of Premier Home Health Care, or professional licensing/certification or accreditation investigations or reviews.
(8) I agree to conform to all rules and regulations of Premier Home Health Care and acknowledge that if my application is accepted and employment engaged, I am an employee at will and have no contractual right of employment.

I agree to the application note, and all subsequent disclaimers.