CHILDREN’S HOME HEALTHCARE

   EMPLOYMENT APPLICATION

               We are an equal opportunity employer

Position Applied For:  _________________________________________Date of Application:  _______________________

Name:  ____________________________________________________________________________________________

            Last                                                         First                                                      Middle

Address:  __________________________________________________________________________________________

   Street                                      City                                           State                                          Zip

Phone:  ________________________________________Mobile/Fax:  _________________________________________

Email Address:  ____________________________________________

Date Available to Start:  _____________________________Social Security Number:  _____________________________

Referred By:            o Internet            o Newspaper            o Friend            o Employee _______________________

                                                                                                                                                         Name

Type of employment desired:               o Full-Time               o Part-Time               o Temporary

Have you ever been convicted of a felony?                                                           o Yes          o No

If yes, please explain:  ________________________________________________________________________________

Have you ever been employed here before?                                                         o Yes          o No

Do you have any relatives currently employed here?                                             o Yes          o No

Can you travel if a job requires it?                                                                       o Yes          o No

Have you ever had your professional license suspended or revoked?                      o Yes          o No

WORK EXPERIENCE

EDUCATION

SKILLS, TRAINING, ETC.

Applicant’s Certification and Agreement

(Please Read Carefully)

Should you be called for an interview, you will be asked to sign this “Certification and Agreement”.

In consideration of being employed, I understand and agree that:

1.     If I misrepresent or deliberately leave out a fact in my application, I may refuse employment or, if employed, I may be terminated.

2.     The employer has my authorization to thoroughly investigate my work and personal and credit history and I hereby consent to take any test, whenever the employer deems if necessary in any employer investigation.  I will hold no person, corporation or organization liable for giving or receiving information in such investigation.

3.     If employed, I may terminate my employment at any time without notice or cause, and the employer may terminate or modify the employment relationship at any time without prior notice or cause.  In consideration of my employment, I agree to conform to the rules and regulations of the employer, and I understand that no department head or representative of the employer, other than the President of the Company, has any authority to enter into any agreement, oral or written, for employment for any specified period of time or to make any agreement or assurances contrary to this policy.

4.     Any doctor, hospital or testing laboratory has my consent to conduct medical or drug test on me, and I hereby give my consent to having all information released for the employer to determine my abilities to perform job duties now or in the future.  I also give my consent to physical searches of myself and my brief case, lunch box, car, locker or any packages or purse I have while on the employer’s premises whether or not I have a lock on such items.

5.     The needs of the employer may make the following conditions mandatory:  overtime, shift work, rotating work schedule, or a work schedule other than Monday through Friday.  I accept these conditions of employment.

6.     The employer is an equal opportunity employer.  The employer does not discriminate in employment and no question on my employment application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

7.     If implied, I understand that my employment is for no definite period of time, and if terminated, the employer is liable only for wages earned as of the date of termination.

8.     I understand that the employer requires all staff to report sanction, convictions, suspensions, censures or revocation (“sanction”) action taken against them by federal, state, local, or other professional entities.  These sanctions may include but are not limited to infractions against professional licensure, criminal history convictions, history of child abuse, managed care organizations, etc.

9.     This application is current and active for only six months.  At the conclusion of this time, if I have not had any contact from the employer and still wish to be considered for employment, it will be necessary for me to fill out a new application.

10.  If employed, I understand that I must abide by the company’s established Service Excellence standards and realize that Service Excellence is a priority of the company.

I have read and agree to the above and hereby certify that the facts I have provided in my employment and application are true and complete.

Date:  _______________________ Signature of Applicant:  ___________________________________________