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815-464-9201
815-464-9202
[email protected]
414 DIXIE HIGHWAY CHICAGO HEIGHTS IL, 60411
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Home
About Us
Services
Application Forms
Training Form
LPN Application
RN Application
Home Health Aide Application
Testimonials
Contact Us
Book An Appointment
815-464-9201
815-464-9202
[email protected]
414 Dixie Highway Chicago Heights IL, 60411
Book An Appointment
Home Health Aide Application
Download Home Health Application
General Information
Date of Application
MM slash DD slash YYYY
Position Applying for:
RN /NP
Home Care Aide
LPN
CNA
Full Name
Date Of Birth
MM slash DD slash YYYY
Email
Social Security Number
Address
Phone
1. Do any of your friends or relatives work here?
Yes
No
If yes, state full name and relationship
2. Are you legally eligible for employment in this country? (Proof of citizenship or immigration status will be required upon employment)
Yes
No
3. Have you been convicted of a felony within the last 7 years
Yes
No
4. Are you currently employed
Yes
No
5. lf you are currently employed, may we contact your employer?
Yes
No
Work Preferences & Availability
1. Are you looking for a full-time or part-time position?
2. Are you available to work weekends?
3. Are you willing and able to service clients throughout the Chicagoland area/ Will County, Lake County (whether by driving or using public transportation)?
Education
Type of School
NAME OF SCHOOL
LOCATION (City, State)
NUMBER OF YEARS COMPLETED
MAJOR & DEGREE
Type of School
NAME OF SCHOOL
LOCATION (City, State)
NUMBER OF YEARS COMPLETED
MAJOR & DEGREE
Type of School
NAME OF SCHOOL
LOCATION (City, State)
NUMBER OF YEARS COMPLETED
MAJOR & DEGREE
Type of School
NAME OF SCHOOL
LOCATION (City, State)
NUMBER OF YEARS COMPLETED
MAJOR & DEGREE
Have you ever been convicted of a crime?
Yes
No
lf yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were conttrritted, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment):
Have you ever worked under a different name?
Yes
No
lf YES, what was it and what was the reason?
Do you have any relatives or friends that work for the company?
Yes
No
lf YES, what is their name?
ln Case of Emergency, Please Contact:
Name
Relation
Phone Number
Previous Employment/Work History
Company
Telephone Number:
Supervisor
Date Started
MM slash DD slash YYYY
Job Title
Date Ended
MM slash DD slash YYYY
Job Duties
Reason for Leaving
Address
Company
Telephone Number:
Supervisor
Date Started
MM slash DD slash YYYY
Job Title
Date Ended
MM slash DD slash YYYY
Job Duties
Reason for Leaving
Address
Company
Telephone Number:
Supervisor
Date Started
MM slash DD slash YYYY
Job Title
Date Ended
MM slash DD slash YYYY
Job Duties
Reason for Leaving
Address
WHAT POSITION ARE YOU APPLYING FOR?
POSITION
COMPANY NAME
TITLE
Regarding Employment Application for VICTORIOUS HOME HEALTHCARE LTD
I certify that the information contained in this application and in any resume provided by me or any party representing my interests is correct and complete to the best of my knowledge. I understand that any false statements, misinterpretations, or omissions mode by me on this application or any supplement to it, will be sufficient grounds for rejection of this application or discharge after employment.
I grant VICTORIOUS HOME HFALTH CARE LTD the right to obtain pertinent information concerning me from former employers, educational institutions, and others, and I release all those providing or requesting such information from any liability that may arise by truthful disclosures or such investigations.
lf I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the Company reserves the some right to terminate my employment at any time with or without cause and without prior notice, except as may be required by law, This application does not constitute on agreement or contract for employment for any specified period or definite duration. I understand thot no representative of the Compony, other than an authorized officer, hos the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by on authorized officer.
I understand it is the Company's policy not to refuse to hire o qualified individual with a disability because of thot person's need for a reasonable accommodation as required by the Americans with Disabilities Act.
I also understand that if I om hired, I will be required to provide proof of identity ond legal work authorization.
Your signature acknowledges you hove read ond agree to the above.
Applicant Signature
Date
MM slash DD slash YYYY
