test - Long Life Home Care LLC

LongLife Home Care LLC
Application

Personal Data

Email Address

Last Name

First Name

Middle

SSN

Home Address

City

State

Zip

Home Phone

Cell Phone

Pager

Today's Date

Emergency Contact Information

Name of Emergency Contact

Relation

Emergency Telephone Number

Position (Job Class) Applying for:

LPN/LVN

CNA

PTA

Clerical

Other:

Date Available:

Work Experience/Skills
Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:
Burn	ENT	Pediatrics	Detox/Drug Rehab
L&D	Rehab	Telemetry	Post Partum
MICU	Nursery	Psychiatry	Orthopedics
NICU	Dialysis	Stepdown	Mother/Baby
PACU	Geriatric	Oncology	Recovery Room
SICU	Pedi ICU	Neurology	Operating Room
CCU	Med/Surg	Open Heart	Emergency Room
Other	Other	Other	Other

Previous Facility Types Worked: Check All That Apply
Hospital	Hospice	Nursing Home	Rehab	Private Duty	Assisted Living / Residential

Language Skills: Other than English, please check any other languages you speak
Spanish	French	German	Other:
Check the type of assignment you are available for
Full-time	Part-time	Contract	Travel

Check the days of the week you are available to work

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Holidays available to work:

License Information
License Type	License/Certification #	State	Expiration Date

Has your professional license ever been suspended, revoked, or under investigation?

Yes

If Yes, please explain:

Certifications: Check all applicable certifications and enter expiration date:
ACLS		BCLS
CPR		PALS
IV		NALS
Other

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Facility/Employer Name:

Date employed

From: To:

Address:

Title:

City / State / ZIP:

Country:

Unit

Number of Beds in Unit:

In Hospital:

Name of Current Immediate Supervisor:

Describe duties and specialty areas:

Telephone #:

Facility/Employer Name	Date Employed	Title
	From: To:
Address	City/State/Zip	Country	Unit

Number of Beds in Unit	Name of Current Immediate Supervisor	Telephone #

Describe duties and specialty areas:		Pay Rate/Salary: Hourly Yearly
		Salary:
Reason for leaving	If this was a travel assignment, name of agency

Are your employment records listed under another name?	Supervisory Experience	May We Contact?
No Yes If yes, what name?	Yes No How often?	Yes No If no, why?
Facility/Employer Name	Date Employed	Title
	From: To:
Address	City/State/Zip	Country	Unit

Number of Beds in Unit	Name of Current Immediate Supervisor	Telephone #

Describe duties and specialty areas:		Pay Rate/Salary: Hourly Yearly
		Salary:
Reason for leaving	If this was a travel assignment, name of agency

Are your employment records listed under another name?	Supervisory Experience	May We Contact?
No Yes If yes, what name?	Yes No How often?	Yes No If no, why?
Please list any other work-related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.

Additional Information:
1. Are you legally authorized to work in the USA? Yes No
2. Have you ever been convicted of a felony? Yes No
3. How were you referred to LongLife Home Care LLC?
Newspaper Trade Publication Job Fair/Open House Internet Site Company Employee - Name:
I understand that I must report all accidents to my immediate supervisor and to LongLife Home Care LLC - No MATTER HOW SLIGHT. Yes
I also understand that I must wear all required personal protection equipment (PPE). Yes
The penalty for not wearing PPE is disciplinary action, up to and including termination.
Signature
Signature: Date:
ACKNOWLEDGMENT (Please read carefully and sign)
In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment. I give LongLife Home Care LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application. I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by LongLife Home Care LLC with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, LongLife Home Care LLC may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release LongLife Home Care LLC, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information. In consideration of my employment and of my being considered for employment by LongLife Home Care LLC, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either LongLife Home Care LLC or I can terminate my employment at any time, with or without cause, and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of LongLife Home Care LLC at any time, can constitute a contract of employment. No representative or agent of LongLife Home Care LLC has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances, in accordance with applicable laws. If I receive an offer of employment, I agree that my continued employment may be contingent on the results. I understand that LongLife Home Care LLC is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional's practice. The Professional fully indemnifies LongLife Home Care LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage, and other responsibilities as found under state prime contract law.
I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.
Applicant Signature: Date:

LongLife Home Care LLC NEW EMPLOYEE BACKGROUND CHECK INFORMATION SHEET
Last Name:
First Name:
Date of Birth:
Place of Birth:
SSN:
Drivers License State and Number:
Sex:
Race:
Eye Color:
Hair Color:
Height:
Weight:
Country of Citizenship (if outside of US):
Address:
City:
State:
Zip:
Phone:
Email:

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- Step 1 of 8

Date / Time

Personal Data

Name

First

Middle

Last

Address

Address Line 1

City

State

Zip Code

Home Phone

Cell Phone

Pager

Emergency Contact Information

Name of Emergency Contact

Relation

Emergency Telephone Number

Job Information

Position (Job Class) Applying for:

RN
PT
LPN/LYN
CNA
OT
PTA
Clerical
Other

Date Available:

Work Experience / Skills

Burn
ENT
Pediatrics
Detox/Drug Rehab
L&D
Telemetry
MICU
Nursery
Psychiatry
Orthopedics
NICU
Dialysis
Stepdown
Mother/Baby
PACU
Geriatric
Oncology
Recovery Room
SICU
Pedi ICU
Neurology
Operating Room
CCU
Med/Surg
Open Heart
Emergency Room
Other
Other
Other

Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:

Previous Facility Types Worked: Check All That Apply-

Hospital
Hospice
Nursing Home
Rehab
Private Duty
Assisted Living / Residential Treatment

Language Skills: Other than English, please check any other languages you speak -

Spanish
French
German
Other:

Check the type of assignment you are available for:

Full-time
Part-time
Contract
Travel

What Language?

Check the days of the week you are available to work:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays

Holidays available to work:

License Type

License/Certification #

State

Expiration Date

License Type

License/Certification #

State

Expiration Date

License Type

License/Certification

State

Expiration Date

Has your professional license ever been suspended, revoked or under investigation?

If Yes, Please explain:

Check all applicable certifications and enter expiration date:

Certifications:

ACLS

Expiration Date

BCLS

BCLS

BCLS

CPR

PALS

PALS

PALS

NALS

NALS

NALS

Other

Other

Other

Work Experience:

List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet{s) if necessary.

Facility/Employer Name:

Address

Address Line 1

City

State

Zip Code

Number of Beds In Unit:

In Hospital:

Describe duties and specialty areas:

of I Zip

Title

Date Employed:

Unit

From:

Name of Current Immediate Supervisor

To:

Telephone #

Facility/Employer Name

Date Employed

From:

To:

Address

Title

City / State / Zip

Unit

Country

Number of Beds in Unit:

Name of Current Immediate Supervisor

In Hospital:

Describe duties and specialty areas:

Telephone #

Pay Rate/Salary:

Hourly

Yearly

May We Contact

If no, why?

Reason for leaving:

If this was a travel assignment, name of agency:

Are your employment records listed under another name?

If yes, what name?

Supervisory Experience:

How often?

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.

Paragraph Text

Additional Information:

Are you legally authorized to work in the USA?

Have you ever been convicted of a felony?

How were you referred to Longlife Home Care LLC?

Newspaper
Trade Publication
Job Fair/Open House
Internet Site
Company Employee

Name:

I understand that I must report all accidents to my immediate supervisor and to Longlife Home Care LLC - - No MATTER HOW SLIGHT.

I also understand that I must wear all required personal protection equipment (PPE). The penalty for not wearing PPE is disciplinary action, up to and including termination.

Signature

Clear Signature

ACKNOWLEDGMENT (Please read carefully and sign)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Longlife Home Care LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application. I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Longlife Home Care LLC with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Longlife Home Care LLC may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Longlife Home Care LLC, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Longlife Home Care LLC, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Longlife Home Care LLC or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Longlife Home Care LLC, at any time, can constitute a contract of employment. No representative or agent of Longlife Home Care LLC has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment, I agree that my continued employment may be contingent on the results.

I understand that Longlife Home Care LLC is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional's practice. The Professional fully indemnifies Longlife Home Care LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage, and other responsibilities as found under state prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

Applicant Signature

Clear Signature

Date

NEW EMPLOYE BACKGROUND CHECK INFORMATION SHEET

Last Name:

First Name:

Date of Birth:

Place of Birth:

SSN:

Drivers License State and Number:

Sex:

Race:

Eye Color:

Hair Color:

Height:

Weight:

Country Of Citizenship (if outside of US):

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

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