River Valley Homecare, Inc - Providing quality home care including respite care, PCA services, physical therapy, occupation therapy, and ventilator assistance
 

APPLICATION FOR EMPLOYMENT

Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veteran’s employment. We are an equal opportunity employer.  * = Required fields    
Name
  
Present Address
First Name: *   Street: *
Last Name: *   City: *
Middle Initial:   State: *
      Zip Code: *
       
Permanent Address
Same as present		  
In case of emergency, Notify:
Street:   Name:
City:   Address:
State:   Phone:
Zip Code:      
Phone Number:  *        
Referred by:      
 
U.S. Military or Naval Service:     Rank:
Present membership in Natl Guard or Reserves?   Yes  No
   
Have you ever been convicted of a crime other than minor traffic violations?   Yes No
  If yes, complete disclosure of criminal conviction information form.

Employment Desired
   
Position:
RN LPN/LVN Homemaker Home Health Aide Clerical
Personal Care Attendant Other 

Do you have a current license for this position?  Yes  No
Current Certification? Yes  No
Have you passed competency testing?  Yes  No
Do you have a certificate?  Yes  No
Do you have a current driver's license?  Yes  No
Do you have a car? Yes  No
Are you employed? Yes  No   If so, may we inquire of your present employer? Yes  No
Have you ever applied to this company before? Yes  No
  When?   Where?
   

Education

  
  Name & location Years
Attended		 Date
Graduated		 Degree/
Certification		  
High School
 
College
 
Additional Training
 
           

Former Employers:
(List below last four employers, starting with last one first)
Date
Month & Year
Name & Address of Employer &
Supervisor's Name
Salary
Position
Reason for leaving
From
To
From
To
From
To
From
To
 

References

  
Give below the names of three work related references.
  Name Address Company / Position Phone
1.
2.
3.
         
   

* I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.

*I hereby agree that, as a condition of employment by the agency, I will promptly inform the agency in writing of any criminal convictions, in any jurisdiction (including all pleas of guilty), other than minor traffic offenses of which I am convicted after today.
 
 
 
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