United Home Health

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION INSTRUCTION

Please complete ALL sections of this application form. INCOMPLETE or UNSIGNED applications will not be considered.
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, sex, age, national origin, marital status, or disability.
Do you need an accommodation to participate in the interview process?

Yes

No

New Hire Process

STEP 1 - Fill out application
STEP 2 - Submit application along with items from checklist.
STEP 3 - After steps 1-2 are completed, your application will be processed. (Please give 5-7 days to check references and necessary background checks.)
STEP 4 - If you are qualified, you will receive a call to schedule your interview

APPLICANT CHECKLIST

ITEMS NEEDED TO COMPLETE APPLICATION PROCESS

Do You Following Requirements?

Yes

No

1. State Issued Driver License:

Yes

No

2. Social Security Card:

Yes

No

3. High School Diploma:

Yes

No

4. GED:

Yes

No

5. College Transcript:

Yes

No

6. Resume:

Yes

No

7. First Aid / CPR Certification Card:

Yes

No

8. TB Skin Test:

Yes

No

PERSONAL DATA

Your Name:

SSN:

DOB:

Address:

City:

State:

Zip code:

Country:

Home Phone:

Cell Phone:

Email:

Driver’s License:

Operator

CDL

CDL Type:

Endorsements:

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis?

Yes

No

Position applying for:

Desired Salary:

Are you available to work, as needed (PRN)? If so, when?

Days available to work (Be specific)

Hours available to work:

No Preference

Thursday

No Preference:

Thursday:

Monday

Friday

Monday:

Friday:

Tuesday

Saturday

Tuesday:

Saturday:

Wednesday

Sunday

Wednesday:

Sunday:

How many hours can you work weekly?

Can you work nights?

Yes

No

Temporary/ Seasonal

Permanent

Full-Time Only

Part-Time Only

Full or Part Time

Date you are available for work?

HAVE YOU EVER BEEN CONVICTED OF A CRIME?

Yes

No

If yes, explain number of conviction(s), nature of offense(s) leading to convictions(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

EDUCATION

Do you have a High School Diploma?

Yes

No

Name of High School:

Duration:

Date Completed:

Certificate earned:

Do you have a College Degree?

Yes

No

Name of College or University:

Major:

Minor:

Duration:

Date Completed:

Do you have Professional Training?

Yes

No

Skill Acquired:

Additional Information That Could Help You Qualify For This Position

Examples include: classes (include date(s)), certificates, current licenses, specific equipment skills and other skills.

WORK EXPERIENCE (1)

Company Name:

Immediate Supervisor:

Complete Address.

Job Title:

Phone:

Fax:

Job Description (duties, skills, equipment used):

Starting Salary:

Ending Salary:

Current Employer?

Yes

No

May we contact this employer?

Yes

No

Date From:

Date To:

Reason for leaving:

WORK EXPERIENCE (2)

Company Name:

Immediate Supervisor:

Complete Address:

Job Title:

Phone:

Fax:

Job Description (duties, skills, equipment used):

Starting Salary:

Ending Salary:

Current Employer?

Yes

No

May we contact this employer?

Yes

No

Date From:

Date To:

Reason for leaving:

WORK EXPERIENCE (3)

Company Name:

Immediate Supervisor:

Complete Address:

Street:

City:

State:

Zip Code:

Job Title:

Phone:

Fax:

Job Description (duties, skills, equipment used):

Starting Salary:

Ending Salary:

Current Employer?

Yes

No

May we contact this employer?

Yes

No

Date From:

Date To:

Reason for leaving:

REFERENCES

LIST REFERENCES (preferably persons who know about your work/training):

Name:

Email:

Phone Number:

The information that you provide on this application is subject to verification. Falsifications or misrepresentations may disqualify you from consideration for employment or, if hired, may be grounds for termination at a later date. Do you want to be informed before we contact your present employer?

With my signature below (typed or written), I certify that all information on this and all attached pages is true, correct and complete to the best of my knowledge and contains no willful falsifications or misrepresentations. I authorize all former employers to release job-related information they may have about me and I release all persons or companies from any liability or responsibility for providing such information.

Print Name :

Date:

Please upload any supporting documentation (Resume, First Aid / CPR Certifications, Transcript or Diplomas, etc.) you have . (Allowed File Type: doc,docx,pdf)
(Max. upload file size: 5MB)

Upload file: Browse

EMPLOYMENT APPLICATION INSTRUCTION

New Hire Process

APPLICANT CHECKLIST

PERSONAL DATA

Days available to work (Be specific)

Contact

Professional Affiliations: