1

Name

2

Present Address

(street, city, state, zip)

City / County
[ you would like to work in]

3

Email Address

4

Home Phone

5

Cell Number

6

If you cannot be reached at any of the above phone numbers, where may we contact you?

7

Are you a US Citizen?  Yes         No  

If not a U.S. citizen, do you have the legal right to remain permanently and work in the U.S.? 

                                      Yes         No  

Immigration # (if applicable): [ NOT NEEDED UNTIL A INTERVIEW IS SCHEDULED ]

8

Information

High School

College

Others

a)

Name of School

b)

City, State, Country

c)

Diploma, Degree or Certificate

d)

Year Completed

Type

Organization or State Issued

Expiration Date

1

2

3

4

Do you consider yourself to be able to perform all of the duties required of the position for which you are applying, without endangering yourself, other employees or patients?

If no, please explain:

Yes         No   

Employer Name

City, State

From-To

Position

Reason for Leaving

1

2

3

Please Send a RESUME to michellegene@rhemacares.com

1.

Primary Position Desired

2.

Availability

Full Time:           Part Time:

Hours per Week desired:

3

Time (From-To) Available

Sunday –

Monday –

Tuesday –

Wednesday –

Thursday –

Friday –

Saturday -

4.

Have you ever worked for this company or any of its affiliates before?     

Yes       No   

5.

Are you 18 years of age or older?     

Yes       No   

6.

Are you currently employed?                    

Yes       No   

May we contact your present employer?

If not, please explain:

Yes       No   

7.

Have you ever been convicted of a felony or crime, within the last five years?

Have you ever been convicted of a misdemeanor which resulted in imprisonment?

Yes       No   

Yes       No   

a.       If yes, explain fully: for what, when and where?

1

Do you have a driver’s license?     

Yes       No   

If NO, are you in the process of obtaining one

If YES, do you feel comfortable driving clients?

Yes       No   

Yes       No   

2

Are you CPR Certified?    

Yes       No    

3

Have you ever worked with Senior Citizens?     

Yes       No   

4

Have you ever worked with Handicapped Individuals?     

Yes       No   

5

Have you ever worked with Children?     

Yes       No    

6

Would you be available to work as a live-in aid? (24-hour care)     

Yes       No   

VII. NOTICE:
This is to inform you that as part of our procedure for processing your Employment Application, we may conduct an investigation in which we will obtain or cause to be obtained a consumer report from consumer reporting agencies. You are specifically notified that this institution may obtain a credit report for purposes of making employment decisions. You have a right under the Fair Credit Reporting Act to know the information contained in your credit file.

VIII.            ATTESTATION
- Signature By my electronic signature below, I hereby declare and attest to the following:

 I understand the above Notice and agree to permit this institution to conduct an investigation as described.  I hereby authorize release of information from my records requested by this institution , who is a prospective employer and agree to cooperate in such investigation .

I agree to hold harmless any third party releasing information in reliance upon this release. It is expressly understood that any information given may be used for the purpose of determining my acceptability for employment.  A photocopy of this authorization shall be deemed as effective as the original.

I further consent to take any required pre-employment physical examinations and any future physical examinations as may be required by this institution, at such times and places as the institution shall designate. 

I understand that I may be required to be photographed as a condition of employment for ID purposes.

I further acknowledge that I will be required to comply with all personnel policies, rules and regulations of the institution and that an infraction may lead to an immediate dismissal.  I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this Application.

I further understand that this institution follows the “Fair Employment Practice Act” of my state and there is no discrimination in the hiring of individuals based on sex, race, religion, age, color, disability, marital status, national origin, ancestry, or physical or mental handicap unrelated to ability to perform the work required. 

I understand that if I am employed, it will be on a probationary basis. Upon termination of employment, I authorize the release of any and all reference information regarding my employment with this Institution.

I authorize the applicable State Board to release all pertinent information regarding my professional license.

I hereby declare, under penalty of perjury and the laws of this State, that the foregoing information in this application is true and correct and that I fully understand the above attestation.

Applicant Signature

X

Date

Please Send a RESUME to michellegene@rhemacares.com