Careers Form

PERSONAL DATA

Date

Last Name *

First Name *

Middle Name *

Social Security Number *

Home Phone Number *

Cellular Phone Number *

Current Address *

City *

State

Zip Code*

Previous Address

City

State

Zip Code

JOB INTERESTS

Position you are applying for *

How were you referred to us?

Date Available for Work?

Expected Salary

Kindly check the applicable area(s) which best match your education/experience/interests

Geriatric Hospice	Hospital
IV/ Infusion Therapy	Pediatrics
Rehabilitation	Home Care
Hospice	Medical/Surgical
Psychiatric	Residential Care
Homemaking	Intermittent Care
Nursing Home	Private Duty
Supplemental Staffing

Please indicate your availability below

Work Status

Full Time

Part Time

Shift

7am - 3pm

3pm - 11pm

11pm - 7pm

Visit Only

EDUCATION BACKGROUND

Please indicate the highest level of education attained:

1	2
3	4
5	6
7	8
9	10
11	12
High School	Associate
Bachelors	Masters

Undergraduate School/College/University

Degree

Year Graduated

Graduate School/College/University

Degree

Year Graduated

GENERAL INFORMATION

Are you legally authorized to work in the USA?

Yes

No

Please provide the necessary documentation proving your eligibility to work in the USA

Have you ever been convicted of a crime or felony? ( Does not apply if the convicted has been removed, record, or was juvenile. )

Yes

No

If yes, please state the conviction and the date of the conviction

Have you ever been previously employed by this agency or its subsidiaries?

Yes

No

If yes, please give the dates and location

Name

Phone

Relationship

PERSONAL REFERENCES

Please provide at least three character references with complete information. (Do not include former employer or relatives. Include only the people you have known for at least one year.)

Name

Address (City, State and Zip)

Phone Number

Job

Year's Known

Name

Address (City, State and Zip)

Phone Number

Job

Year's Known

Name

Address (City, State and Zip)

Phone Number

Job

Years Known

WORK HISTORY

Company Name (present or most recent employer)

Company Address

City

State

Zip Code

From

To

Wage

Per Hour

Annual

Please describe your job responsibilities and/or duties

Supervisor's Name

Phone Number

May We Contact?

Yes

No

Reason for Leaving

Company Name (present or most recent employer)

Company Address

City

State

Zip Code

From

To

Wage

Per Hour

Annual

Please describe your job responsibilities and/or duties

Supervisor's Name

Phone Number

May We Contact?

Yes

No

Reason for Leaving

Company Name (present or most recent employer)

Company Address

City

State

Zip Code

From

To

Wage

Per Hour

Annual

Please describe your job responsibilities and duties

Supervisor's Name

Phone Number

May We Contact

Yes

No

Reason for Leaving

In accordance with Title VI of the Civil Rights Act of 1964 and its implementing regulation, Angels Over Us is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRMINATE AGAINST RACE, COLOR, SEX, CREED, NATIONAL ORIGIN OR COMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI. In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation, Angels Over Us, WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP. In accordance with the Age Discrimination Act of 1975 and its implementing regulation, Angels Over Us, WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision of services, unless age is a factor necessary to the normal operation or the achievement of any statutory objective. In accordance with the Americans with Disabilities Act of 1992 (42 USC §12101) and its implementing regulations, (private employers with more than 25 agency personnel), Angels Over Us, WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment that substantially limits a major life activity, or for which ther is a record of impairment or which causes the individual to be regarded as impaired.

This is to certify that all the information I provided are true and accurate to the best of my knowledge.

Full Name

Date

Attach Resume

Please indicate the person to contact in case of emergency