Employment Application – Nightingale’s Nursing & Attendants : Nightingale’s Nursing & Attendants

URL

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Position Applying For*

Name*

First Last

Maiden Name/Alias

Date of Birth

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Emergency Phone*

Email*

Special Training? Where? When?

If family member, how long?

How did you hear about us?

If you chose 'Nightingale's Employee', who is it?

Have you ever been employed with us before?*

Yes
No

If Yes, When?

Former Employer (most recent first)

Start Date

End Date

Currently Employed?

Yes
No

Employer Name

Phone

Position

Last Salary

Reason for Leaving (be specific)

Former Employer (#2)

Start Date

End Date

Currently Employed?

Yes
No

Employer Name

Phone

Position

Last Salary

Reason for Leaving (be specific)

Former Employer (#3)

Start Date

End Date

Currently Employed?

Yes
No

Employer Name

Phone

Position

Last Salary

Reason for Leaving (be specific)

Education

High School

College – Did you graduate?

If yes, what degree did you earn?

Character References (other than relatives or previous employers)

Name

First Last

Years Known

Phone

Relationship

Name

First Last

Years Known

Phone

Relationship

Name

First Last

Years Known

Phone

Relationship

Misc.

I certify that I have dependable, insured transportation.*

Yes
No

I certify that I have access to a telephone for easy communication*

Yes
No

I certify that I have a valid driver's license*

Yes
No

Have you been convicted of a crime within the last 10 years?*

Yes
No

If yes, please describe

I understand that my job is not complete until I turn in my Care Plan/Time Sheet and agree to do so prior to receiving payment from Nightingale's*

Yes
No

I understand that dependability is extremely important to home care. I will notify the office at least 3 days prior to requesting time off*

Yes
No

I understand that clients have the option of refusing my services at any time and this may be of no fault of Nighingale's*

Yes
No

I understand that I will be required to participate in 10 hours of in service training annually and will attend mandatory meetings*

Yes
No

I certify that I have no prior mental or physical impairments that will affect or limit my work capabilities for any assignments*

Yes
No

I agree to accept responsibility for working safely*

Yes
No

I agree to never accept money or tips of any kind from a client without Nightingale's permission*

Yes
No

I understand that asking to borrow money from a client is grounds for immediate termination*

Yes
No

I understand that entering false time on time-sheets may be fraud and is cause for termination*

Yes
No

I certify that if I have ever had a workman's compensation case against an employer for personal injury that I am 100% cleared by my physician to return to work*

Yes
No

Counties

Nightingale's provides services to the following counties. Please select every county in which you are willing to work*

I am willing to work within a 50 mile radius of selected counties*

Yes
No

Resumé (Not Required)

Attach resumé

Max. file size: 128 MB.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of my background through SLED checks and all other information provided and release Nightingale's from all liability from any damage that may result from using such information. I also understand and agree that no representative of Nightingale's has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing, unless in writing and signed by an authorized Nightingale's representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans With Disabilities Act (ADA) and other relevant federal and state laws. Do you agree with the authorization statement?*

Application