Job Application - High Point Health

Date

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Social Security Number

If necessary, the best time to reach you at home is:

Are you legally eligible for employment in this country?*

Yes
No

Date available for work:

Hours desired:*

Full Time
Part Time
Temporary

Have you ever been convicted of a felony?*

Yes
No

If yes, please explain:

Have you ever worked/cared for or with pediatrics?*

Yes
No

If yes, with whom?

What times, hours and shifts are you interested in?

Employment History

List your last four (4) employers, starting with the most recent. Explain any gaps in employment in the comment section below.

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Dates Employed

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Immediate Supervisor and Title

Reason for Leaving

May we contact for reference?

Yes
No

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Dates Employed

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Immediate Supervisor and Title

Reason for Leaving

May we contact for reference?

Yes
No

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Dates Employed

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Immediate Supervisor and Title

Reason for leaving

May we contact for reference?

Yes
No

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Dates Employed

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Immediate Supervisor and Title

Reason for leaving

May we contact for reference?

Yes
No

Comments

Education Background

A) List the last 3 schools attended, starting with the last one. B) List number of years completed. C) Indicate degree or diploma earned, if any. D) List grade point average or class rank. E) Major and or Minor field of study.

School

Remember to include name of school and years completed, degree/diploma, grade point average or class rank and Major/Minor.

School

Remember to include name of school and years completed, degree/diploma, grade point average or class rank and Major/Minor.

School

Remember to include name of school and years completed, degree/diploma, grade point average or class rank and Major/Minor.

References

List name and telephone number of 3 references.

Reference

List name, telephone and dates of service

Reference

List name, telephone and dates of service

Reference

List name, telephone and dates of service

What do you like most about doing home health care?

What is your RN/LPN Nursing License Number?

Consent*

I agree

It is understood and agreed that any misrepresentation by me in this application is sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed.

I give the Employer the right to investigate all references and to secure additional information about me if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other person, corporation or organizations for furnishing such information.

Name of Applicant*

Date*

Job Application:

Employment History

Education Background

References