* = Required Information
Today's Date:*
Personal Data
Last Name *
First Name *
Middle
SSN *
Home Address *
City *
State *
Zip Code *
Email Address *
Home Phone *
Cell Phone
Pager
Date of Birth *
Emergency Contact Information
Name of Emergency Contact
Relation
Emergency Telephone Number
Job Information
Position (Job Class) Applying for:
RN PT LP/VN CNA
OT PTA Clerical Other
Date Available:
Work Experience/Skills
Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:
Burn
L & D
MICU
NICU
PACU
SICU
CCU
Other
ENT
Rehab
Nursery
Dialysis
Geriatric
Pedi ICU
Med/Surg
Other
Pediatrics
Telemetry
Psychiatry
Stepdown
Oncology
Neurology
Open Heart
Other
Detox/Drug Rehab
Post Partum
Orthopedics
Mother/Baby
Recovery Room
Operating Room
Emergency Room
Other
Previous Facility Types Worked: Check All That Apply
Hospital Hospice Nursing Home
Rehab Private Duty Assisted Living / Residential Treatment
Language Skills: Other than English, please check any other languages you speak
Spanish French German Other
Check the type of assignment you are available for:
Full-time Part-time Contract Travel
Check the days of the week you are available to work:
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday Holidays available to work
License Type
License/Certification #
State
Expiration Date
License Type
License/Certification #
State
Expiration Date
License Type
License/Certification #
State
Expiration Date
Has your professional license ever been suspended, revoked or under investigation?
Yes No
If Yes, Please explain:
Certifications: Check all applicable certifications and enter expiration date:
ACLS Expiration Date: Other Expiration Date:
BCLS Expiration Date: IV Expiration Date:
CPR Expiration Date: NALS Expiration Date:
PALS Expiration Date:
Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.
Facility/Employer Name
Date Employed
From: To:
Address
Title
City/State/Zip
Country
Unit
Number of Beds in Unit:
In Hospital:
Name of Current Immediate Supervisor
Describe duties and specialty areas:
Telephone #:
Pay Rate/Salary:
Hourly Yearly:
May We Contact:
Yes No

If No, why?
Reason for leaving:
If this was a travel assignment, name of agency:
Are your employment records listed under another name?
No Yes

If yes, what name? 		Supervisory Experience:
No Yes

No - How often?
Facility/Employer Name
Date Employed
From: To:
Address
Title
City/State/Zip
Country
Unit
Number of Beds in Unit:
In Hospital:
Name of Current Immediate Supervisor
Describe duties and specialty areas:
Telephone #:
Pay Rate/Salary:
Hourly Yearly:
May We Contact:
Yes No

If No, why?
Reason for leaving:
If this was a travel assignment, name of agency:
Are your employment records listed under another name?
No Yes

If yes, what name? 		Supervisory Experience:
No Yes

No - How often?
Facility/Employer Name
Date Employed
From: To:
Address
Title
City/State/Zip
Country
Unit
Number of Beds in Unit:
In Hospital:
Name of Current Immediate Supervisor
Describe duties and specialty areas:
Telephone #:
Pay Rate/Salary:
Hourly Yearly:
May We Contact:
Yes No

If No, why?
Reason for leaving:
If this was a travel assignment, name of agency:
Are your employment records listed under another name?
No Yes

If yes, what name? 		Supervisory Experience:
No Yes

No - How often?
Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.
Additional Information:
1. Are you legally authorized to work in the USA?
Yes No
2. Have you ever been convicted of a felony?
Yes No
3. Can you pass a pre-employment drug test?
Yes No
4. How were you referred to Alpha Home Health Care?
Newspaper
Trade Publication
Job Fair/Open House
Internet Site
Company Employee - Name
I understand that I must report all accidents to my immediate supervisor and to Alpha Home Health Care - - No MATTER HOW SLIGHT.
I also understand that I must wear all required personal protection equipment (PPE).
The penalty for not wearing PPE is disciplinary action, up to and including termination.

ACKNOWLEDGMENT (Please read carefully and sign)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Alpha Home Health Care permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Alpha Home Health Care with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Alpha Home Health Care may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Alpha Home Health Care, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Alpha Home Health Care, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Alpha Home Health Care or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Alpha Home Health Care, at any time, can constitute a contract of employment. No representative or agent of Alpha Home Health Care, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Alpha Home Health Care is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional's practice. The Professional fully indemnifies Alpha Home Health Care against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.