ALTRANAIS HOME CARE LLC
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Satisfaction Survey
Employee Application Form
SECTION 1
APPLICANT'S INFORMATION
*
Indicates required field
Name
*
First
Last
DATE OF BIRTH
*
CURRENT ADRESS
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
SS#
*
EMERGENCY CONTACT
(person not living with you)
EMERGENCY CONTACT NAME
*
EMERGENCY CONTACT NAME
*
Emergency contact Number
*
Relationship
*
Emergency contact Number
*
Relationship
*
GENERAL QUESTIONS
Have you ever applied for employment with this Agency?
*
YES
NO
How many hours a week are you available for work?
*
Are you legally eligible for employment in the United States?
*
YES
NO
How did you learn of our organization
*
NEWS PAPER
GOOGLE
EMPLOYEE
OTHER
SHIFTS AVAILABLE TO WORK
*
MORNING
EVENING
WEEKENDS
Position applying for:
*
RN
LPN
CNA
OTHER
IF OTHER, PLEASE SPECIFY
*
EDUCATION
COLLEGE
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
DEGREE
*
YEARS
*
MAJOR
*
Vo-Tech or Trade
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
DEGREE / DIPLOMA
*
YEARS
*
MAJOR
*
HIGH SCHOOL / GED
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
DEGREE / DIPLOMA
*
YEARS
*
COURSE OF STUDY
*
EMPLOYEMENT HISTORY
---
List the last THREE years employment history, starting with the most recent employer
.
EMPLOYER 1
Company Name
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
DATES OF EMPLOYMENT:
FROM
*
TO
*
Starting Pay
*
Reason for leaving
*
Enter "CURRENT" if current job.
EMPLOYER 2
COMPANY NAME
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
DATES OF EMPLOYMENT:
FROM
*
TO
*
STARTING PAY
*
Reason for leaving
*
Enter "CURRENT" if current job.
EMPLOYER 3
COMPANY NAME
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
DATES OF EMPLOYMENT:
FROM
*
TO
*
STARTING PAY
*
Reason for leaving
*
Enter "CURRENT" if current job.
Was your last name different from your present name during the above listed jobs?
*
YES
NO
If Yes, what was your name?
*
If No, Enter N/A
Are you currently employed?
*
YES
NO
Do you have reliable transportation?
*
YES
NO
PROFESSIONAL REFERENCES
Persons who can furnish information about job performance.
PROFFESIONAL REFERENCE 1
REFERENCE Name
*
First
Last
Reference Phone Number
*
Reference Address
*
Line 1
Line 2
City
State
Zip Code
Country
PROFFESIONAL REFERENCE 2
REFERENCE Name
*
First
Last
Reference Phone Number
*
Reference Address
*
Line 1
Line 2
City
State
Zip Code
Country
PROFFESIONAL REFERENCE 3
REFERENCE Name
*
First
Last
REFERENCE Phone Number
*
REFERENCE Address
*
Line 1
Line 2
City
State
Zip Code
Country
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
*
YES
NO
NOTE: Conviction will not necessarily disqualify an applicant from employment.
If yes, describe in full:
*
IF NO, ENTER N/A
Are you capable of performing the job set forth in the job description?
*
YES
NO
If you answered No, which job requirement can you not meet?
*
IF YES, ENTER N/A
CREDENTIALS / SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED
List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
*
SECTION 2
DRIVER’S LICENSE
Upload File
*
Max file size: 20MB
SOCIAL SECURITY CARD
Upload File
*
Max file size: 20MB
AUTO INSURANCE
Upload File
*
Max file size: 20MB
CPR CARD
Upload File
*
Max file size: 20MB
PPD / TUBERCULOSIS
Upload File
*
Max file size: 20MB
DIPLOMA / DEGREE OR
TRANSCRIPT
Upload File
*
Max file size: 20MB
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.
I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.
I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time
.
AGREEMENT
*
I AGREE
ELECTRONIC SIGNATURE
*
TODAY'S DATE
*
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Home
COVID-19
About
Services
Resources
Contact & Complaints
Satisfaction Survey
Employee Application Form