Step 1 of 8: 13%
Step 1 of 8

Applicant Information

Name is required.
Please select an option.
List the other name(s) is required.
Please select at least one option.
Other is required.

Address

Street Address is required.
Address Line 2 is required.
City is required.
Zip Code is required.
Home Phone is required.
Cell Phone is required.
Please provide a valid email address.
Social Security Number is required.
Driver's License Number is required.
Please provide a valid enter expiration date.
Please select an option.
Explain is required.
Please select an option.
List the second language other than english is required.
Please upload a file.
Step 2 of 8

Employment Information

What days and hours are you available to work? is required.
Please provide a valid date available for work.
Please select an option.
Other is required.
Step 3 of 8

Emergency Contact Information

Name

First Name is required.
Last Name is required.
Phone is required.
Relationship to you? is required.

Address

Street Address is required.
Address Line 2 is required.
City is required.
Zip Code is required.
Step 4 of 8

Education

High School is required.
City and State is required.
Years attended? is required.
Please select an option.
Name of the degree/diploma or certificate awarded? is required.
Vocational Training School is required.
City and State is required.
Years attended? is required.
Please select an option.
Name of the degree/diploma or certificate awarded? is required.
College is required.
City and State is required.
Years attended? is required.
Please select an option.
Name of the degree/diploma or certificate awarded? is required.
Please select an option.
Please provide a valid cpr certification expiration date.
Nursing or CNA License Number (If Applicable) is required.
Please provide a valid license expiration date.
Step 5 of 8

Employment History

Current or Most Recent Employer (Employer #1) is required.
Position/Job Title is required.
Street Address is required.
Address Line 2 is required.
City is required.
Zip Code is required.
Please select an option.
Phone is required.
Please provide a valid what was your salary or hourly pay?.
Reason for leaving? is required.
Name of Supervisor is required.
Supervisor's Phone Number is required.
Please enter a valid brief description of your job duties/responsibilities.
Please enter a valid explain any gap in employment between employer #1 and employer #2.
Employer #2 Name is required.
Position/Job Title is required.
Street Address is required.
Address Line 2 is required.
City is required.
Zip Code is required.
Please select an option.
Phone is required.
Please provide a valid what was your salary or hourly pay? .
Reason for leaving? is required.
Name of Supervisor is required.
Supervisor's Phone Number is required.
Please enter a valid brief description of your job duties/responsibilities.
Please enter a valid explain any gap in employment between employer #2 and employer #3.
Employer #3 Name is required.
Position/Job Title is required.
Street Address is required.
Address Line 2 is required.
City is required.
Zip Code is required.
Please select an option.
Phone is required.
Please provide a valid what was your salary or hourly pay? .
Reason for leaving? is required.
Name of Supervisor is required.
Supervisor's Phone Number is required.
Please enter a valid brief description of your job duties/responsibilities.
Please enter a valid explain any gap in employment between employer #3 and employer #4.
Employer #4 Name is required.
Position/Job Title is required.
Street Address is required.
Address Line 2 is required.
City is required.
Zip Code is required.
Please select an option.
Phone is required.
Please provide a valid what was your salary or hourly pay? .
Reason for leaving? is required.
Name of Supervisor is required.
Supervisor's Phone Number is required.
Please enter a valid brief description of your job duties/responsibilities.
Please enter a valid explain any gap in employment between employer #4 and employer #5.
Employer #5 Name is required.
Position/Job Title is required.
Street Address is required.
Address Line 2 is required.
City is required.
Zip Code is required.
Please select an option.
Phone is required.
Please provide a valid what was your salary or hourly pay? .
Reason for leaving? is required.
Name of Supervisor is required.
Supervisor's Phone Number is required.
Please enter a valid brief description of your job duties/responsibilities.
Step 6 of 8

Professional References

Please list three individuals below, who have knowledge of your work performance during the last five years.

Please select an option.
Name (Reference 1) is required.
Title is required.
Phone is required.
How does this individual know of your work performance? is required.
How long has this individual known you? is required.
Name (Reference 2) is required.
Title is required.
Phone is required.
How does this individual know of your work performance? is required.
How long has this individual known you? is required.
Name (Reference 3) is required.
Title is required.
Phone is required.
How does this individual know of your work performance? is required.
How long has this individual known you? is required.
Step 7 of 8

Eligibility and Background Questions

Non-Discrimination

Our agency prohibits discrimination against and harassment of any employee or any applicant for employment because of race, color, national or ethnic origin, age, religion, disability, sex, sexual orientation, gender identity and expression, veteran status or any other characteristic protected under applicable federal, state or local laws.

Please select an option.
Please select an option.
Please select an option.
Please select an option.
Please select an option.
Please enter a valid provide specifics, including dates, plea, verdict or finding of guilt, location and current status.
Please select an option.
Please enter a valid explain.
Please select an option.
Please enter a valid list their name(s) and relationship to you.
Please select an option.
Please enter a valid indicate the name of the company and your position.

If hired, there may be clients that cannot be left unattended until your scheduled relief has arrived.

Please select an option.
Please enter a valid explain.
Please select an option.
Please enter a valid explain.
Please select an option.
Step 8 of 8

Acknowledgements

I hereby certify that the foregoing answers are true and complete to the best of my knowledge. I understand that any misrepresentation, falsification or omission of facts on this application or other forms that I may submit in connection with my application for employment, will be sufficient cause not to hire or cause to terminate my employment whenever discovered. I authorize the authorities of Frances Health Services (the “Agency”) to investigate references and all other statements made on this application and authorize any entity or individual to provide information related to this application including but not limited to: employment records, including attendance records, work performance, disciplinary reports, letters of reprimand, involuntary termination information and other disciplinary action, without giving me notice of such disclosure. I authorize the Agency to make inquiries of courts and law enforcement agencies for records of prior convictions. I acknowledge that I am not obligated to disclose sealed or expunged records of convictions or arrests, and I understand that the Agency will not consider such information in making any employment decision. I agree to cooperate fully with the Agency's background checking process, including, but not limited to executing any additional consent forms necessary to conduct background checks or drug testing. If a conditional job offer is extended, I hereby give permission to conduct a pre-employment screening, which may include background checks, drug screening and a complete physical examination. I expressly agree not to hold the Agency liable in any manner in connection with the investigations and inquiries described above. I understand that if I become employed I will abide by all Agency rules and policies. I also understand that employment with the Agency is "employment at will" and that my employment and compensation may be terminated, with or without cause, with or without notice, at any time at the option of the Agency or myself. This application is not a contract or guarantee of employment.

Testing Authorization

If offered a position with the Agency, I hereby agree to any legally permitted physical, psychological, competency, skill, drug, or medical test required by the Agency as a condition of employment.

Investigation Authorization

I authorize initial and post-hire investigations into all statements and references contained in this application. Said investigation may include: OIG Exclusion List Verification, Aide Certification Verification, Vehicle Insurance Verification, Fingerprint Clearance Card Verification, Credit, Driving, Criminal background, reference checks, and other background checks.

Work Hazards

I understand that if I accept employment with the Agency, I may be exposed to potential hazards related to the provision of homecare services within private residences or medical facilities. Such hazards include but are not limited to physical exertion related to heavy lifting, continuous motion, standing for long periods of time, and exposure to on the job chemicals such as cleaning agents and medications.

Agreement

By typing my initials and my complete name below, I acknowledge that I have read and understood the policies and conditions contained herein and agree to be bound by them if employed by Frances Health Services.

Initials is required.
Full Name is required.
Please provide a valid enter todays date.

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