Employment Application / Eagles Wings Home Health

Basic Information：

Position applying for
Position applying for
Date of application
Date of application
Referral source
Referral source

Basic Information：

First Name
First Name
Middle Name
Middle Name
Last Name
Last Name
Email
Email	

Current Address：

Name：
Name：
Street Address：
Street Address：
ZIP/Postal code:
ZIP/Postal code:
City/Town:
City/Town:
State/Province:
State/Province:
Country and Region：
Country and Region：	
How long at this address?
How long at this address?
Cell Number
Cell Number
Alternative Number
Alternative Number

Basic Information：

Have you previously worked for this agency?
Have you previously worked for this agency?
Are you legally eligible to work in the United States? (Proof of eligibility is required.)
Are you legally eligible to work in the United States? (Proof of eligibility is required.)
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check and may include: credit check, motor vehicle check, and drug screen. Employment is contingent upon background screening. Social Security Number:
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check and may include: credit check, motor vehicle check, and drug screen. Employment is contingent upon background screening. Social Security Number:
Do you have reliable transportation to and from work and for travel between worksites, if required?
Do you have reliable transportation to and from work and for travel between worksites, if required?
Do you have any relatives currently employed by this agency?
Do you have any relatives currently employed by this agency?
If yes, please list:
If yes, please list:
Are you able to perform the essential function of the job for which you are applying, with or without reasonable accommodations?
Are you able to perform the essential function of the job for which you are applying, with or without reasonable accommodations?
If no, describe the functions that cannot be performed:
If no, describe the functions that cannot be performed:
Have you been convicted of rape, exploitation, battery, neglect, or theft within the past 10 years?
Have you been convicted of rape, exploitation, battery, neglect, or theft within the past 10 years?
Have you been convicted of a felony within the past 10 years?
Have you been convicted of a felony within the past 10 years?

Educational Background

	Type of School	Name/City	How Many Years Attended	Graduated	Course/Major
High School /GED
College


High School /GED
College

Employment History #1
List your last three (3) employers, assignments, or volunteer activities. Please start with the most recent, including military experience.

Employer:
Employer:
Telephone
Telephone
Address
Address
Job Title
Job Title
Immediate Supervisor and Title:
Immediate Supervisor and Title:
Reason for leaving:
Reason for leaving:
Hourly rate ($/hr) Salary Start
Hourly rate ($/hr) Salary Start
Hourly rate ($/hr) Salary Final
Hourly rate ($/hr) Salary Final
Date Employed (From)
Date Employed (From)	
Date Employed (To)
Date Employed (To)	
Summarize nature of work performed and job responsibilities:
Summarize nature of work performed and job responsibilities:
May we contact for reference/verification?
May we contact for reference/verification?

Employment History #2

Employer
Employer
Telephone
Telephone
Address
Address
Job Title
Job Title
Immediate Supervisor and Title:
Immediate Supervisor and Title:
Reason for Leaving
Reason for Leaving
Hourly rate ($/hr) Salary Start
Hourly rate ($/hr) Salary Start
Hourly rate ($/hr) Salary Final
Hourly rate ($/hr) Salary Final
Date Employed (From)
Date Employed (From)
Date Employed (To)
Date Employed (To)
Summarize nature of work performed and job responsibilities:
Summarize nature of work performed and job responsibilities:
May we contact for reference/verification?
May we contact for reference/verification?

Employment History #3

Employer
Employer
Telephone
Telephone
Address
Address
Job Title
Job Title
Immediate Supervisor and Title:
Immediate Supervisor and Title:
Reason for Leaving
Reason for Leaving
Hourly rate ($/hr) Salary Start
Hourly rate ($/hr) Salary Start
Hourly rate ($/hr) Salary Final
Hourly rate ($/hr) Salary Final
Date Employed (From)
Date Employed (From)	
Date Employed (To)
Date Employed (To)	
Summarize nature of work performed and job responsibilities:
Summarize nature of work performed and job responsibilities:
May we contact for reference/verification?
May we contact for reference/verification?

Comments and other skills, licenses/certifications and qualifications:

10.

REFERENCES:*

Please see the attached Reference Release forms.

List name and telephone number of three (3) professional references that are not related to you. If not applicable, list school or personal references that are not related to you whom have knowledge of your work ethic, experience and abilities. Please use one Reference Release form for each reference. By signing below, I am giving consent for the company to contact my designated references and my current and former places of employment.

I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date. I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of the agency other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s).

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

Signature： Date： // //

11.

Professional Reference Check Form
**APPLICANT – FILL OUT TOP PORTION ONLY**

Candidate Name
Candidate Name
Applicationo Date
Applicationo Date	
Reference Name
Reference Name
Title
Title
Relationship
Relationship
Years Known
Years Known
Phone
Phone
Email
Email	
Address
Address

12.

I give my express permission to contact the reference named above and release all parties from any liability*

from providing any reference.

Signature Date:

13.

** THIS PORTION FOR HR ONLY **

Date of Contact
Date of Contact	
Name of Contact
Name of Contact
Contacted via:
Contacted via:
What capacity do you know this person?
What capacity do you know this person?
Company Name:
Company Name:
Date employed (from)
Date employed (from)	
Date employed (to)
Date employed (to)	
Position(s) held
Position(s) held
Is this person eligible for rehire?
Is this person eligible for rehire?
Is there anything else that you would like to say about this person?
Is there anything else that you would like to say about this person?
Person taking reference:
Person taking reference:

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