Dubols Home Care - Elder Care Provider Application Form

PERSONAL INFORMATION:

Name (First/Last): SSN:

Address: County:

City: State: Zip:

Home phone: Best time to call: Email:

Cell phone: Best time to call:

EMERGENCY CONTACT:

Emergency Contact Name: Emergency Contact Number:

Address: Relationship:

BACKGROUND:

Have you ever been convicted of a crime? Yes No If yes please explain below.

A "yes" answer will not automatically disqualify you from employment but will be considered only as it is relevant to employment and compliance with state law.

Are you 18 years or older? Yes No

Are you legally entitled to work in the U.S.? Yes No

Do you drive a car? Yes No

If so, will you drive to work? Yes No
License Number: Issued State:

Do you smoke? Yes No

Are you a U.S. citizen? Yes No

If not, are you a resident alien? Yes No Alien Registration Number:

JOB POSITION INFORMATION :

I am applying for a position as an: LPN LPV RN

LPN/LPV/RN License Number: State Issued:

Will you accept (check all that apply): FT PT PRN Days Evenings Nights Weekends

Number of hours willing to work: Time(s) not available to work:

Can you be called at the last minute in case of an emergency? Yes No

SKILLS:

Please indicate whether you have assisted or performed the following tasks:

Pediatrics Yes No

Tube Feeding Care Yes No

Skilled Assessment Yes No

Skilled Observation Yes No

Wound Care Yes No

Total Parenteral Nutrition Yes No

Respiratory Treatment Yes No

Catheter Care Yes No

Incontinence Care Yes No

Ostomy Care Yes No

EDUCATION:

High School Name: City/State:

Diploma Received? Yes No

College Name: City/State:

Attended from: Attended to:
Degree Earned:
Major/Minor:

Other: City/State:

Attended from: Attended to:
Certificate/Diploma:

Special Skills or Courses:

EMPLOYMENT HISTORY:

Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional space is required.

Company Name:

       City:    State:    Zip:
       Position:    From:    To:
       Describe job responsibility:
       May we contact Employer? Yes No
       Supervisor's Name & Phone Number:

Company Name:

       City:    State:    Zip:
       Position:    From:    To:
       Describe job responsibility:
       May we contact Employer? Yes No
       Supervisor's Name & Phone Number:

Company Name:

    City:    State:    Zip:
       Position:    From:    To:
       Describe job responsibility:
       May we contact Employer? Yes No
       Supervisor's Name & Phone Number:

How were you referred to us?

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer- reporting bureaus, to verify any information including, but not limited to, criminal history. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. CHECK HERE IF YOU AGREE:

Type Your Name: Type Date:

Signature: ______________________________________ Date: __________________

If submitting form via this online form, you will be asked to sign when visiting our office.

If you feel uneasy submitting your personal information over the Internet, please print this form and send it to us via postal service. By submitting this form via Internet, you indemnify Dubols of any responsibilities for the misuse of personal information by others.