DIVINE HOME HEALTH AGENCY LLC
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 disability.
Information transmitted from this website is SAFE and SECURE.
The estimated time of completing this application is 20 minutes.

Your Full Name

 First: Middle: Last:
Present Address City/State/Zip Address: City: State Zip:
  Email:

Telephone Number
(Enter area code and telephone)

 Area Code/Number


Are You at Least 18 Years Old? 		Social Security #:



Position Applying for

Check all that apply.



Pool Shift Day Night Evening Weekend

  Salary Requirement: Date Available
If you are not a US Citizen, have you the legal right to remain permanently in the US?
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?



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?



If Yes, please give date, place and nature below
Are you presently charged with any violation of the law other than traffic violation?

If Yes, please give date, place and nature of charges below
EDUCATION Name, location & Degree Year attended Year Graduated
High School Name,Location, Degree





Year Graduated

College

 Name,Location, Degree





Year Graduated
College Name,Location, Degree


Year Graduated
Other Name,Location, Degree
 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:
EMERGENCY  
In case of an emergency notify: First Name: Last:
Address: City: State Zip
Email:
WORK HISTORY Start with the most recent one.
Company Name
Address/City/State/Zip/Phone 		Company Name:
State Zip Phone:
  Supervisor: Contact Supervisor?



  Date Started Date Left DD/MM/YYYY




Reason for leaving:

Last Salary:
  Describe your job title, responsibility and accomplishments:
Company Name Company's Name:
State Zip Phone:
  Supervisor: Contact Supervisor?
  Date Started Date Left DD/MM/YYYY



Last Salary
  Describe your job title, responsibility and accomplishments:
Company Name Company's Name:
State: Zip Phone
  Supervisor: Contact Supervisor?
  Date Started Date Left DD/MM/YYYY




Reason for leaving:

Salary
  Describe your job title, responsibility and accomplishments:
Personal References
Please review and sign

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.

I Accept (By checking, you have signed the application. The application will not be proccessed if not checked)
Enter your Name:
Date Signed DD/MM/YYY