* = Required Information

Dependable Healthcare
Application for Employment
It is this facility's policy to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, or disablity.
Applicant Name: *
Present Address: *
City: *   State: *   Zip: *
Phone: *   Social Security Number:  
Are you at least 18 years old? YesNo
Position Applying For: * Full Time Part Time Per Visit
Part Time Pool
Shift: Day Night Evening W/E
Salary Requirements:   Date Available:  
If you are not a US Citizen, have you the legal right to remain permanently in the US?
YesNo
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
YesNo
Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?
YesNo
If Yes, please give date, place and nature of each such conviction.
Are you presently charged with any violation of the law other than traffic violation?
YesNo
If Yes, give date, place and nature of each such conviction.
Educational History
Type of School Name & Location of School Choose Last
Year Attended
Graduated Degree
High School 9 10 11 12
College 1 2 3 4
College 1 2 3 4
Other From: To:
List professional licenses you possess. Indicate type of license, number and state
List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin or disability.
List languages spoken other than English:
List other skills applicable to the position for which you are applying, including computer experience typing speed, etc:
In case of an emergency notify:
Name:   Relation: Number:
Work History
Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient
Company Name
Complete Address include City/State/Zip
Phone Number
Supervisor's Name
Date Started

Date Left
Type of Business

Salary
Full Time Part Time
Per Visit
Reason For Leaving
OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments
Company Name
Complete Address include City/State/Zip
Phone Number
Supervisor's Name
Date Started

Date Left
Type of Business

Salary
Full Time Part Time
Per Visit
Reason For Leaving
OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments
Company Name
Complete Address include City/State/Zip
Phone Number
Supervisor's Name
Date Started

Date Left
Type of Business

Salary
Full Time Part Time
Per Visit
Reason For Leaving
OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments
PERSONAL REFERENCES: (Name, Phone, Relationship)

In making application for employment:
  • I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
  • I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
  • I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.
  • I understand, if I am an unlicensed person who has direct patient contact, that the agency will perform a criminal history check per State Regulations.
Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
Date: *

* Security Code
  Security Code