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Employment Application

* Marked fields are required

 
Last Name * First Name* MI
 
Address: *
 
City * State * Zip (5 digits) *
 
Phone * (SAME AS CELL ) Cell Phone Email
 
Emergency Contact * Phone * Relationship *
 
Position Appliying For: *  
 
I have the following scheduling restrictions
 

EDUCATION

Type * Name of Institution * Degree *
 

LICENSE INFORMATION

License Type: * License Number Expiration
 

GENERAL INFORMATION:

Do you have any pending issues with Illinois Department of Professional Regulations? Or any suits pending against you in connection with you professional license. Yes / No (check one) *
 
Are you legally authorized to work in the USA?
Yes / No (check one) *
(Should you ever become employed by AHHC you will be required to provide documentation proving your eligibility to work in the USA.)
 
Have you ever been convicted of a felony or misdemeanor crime?
Yes / No (check one) *
This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction. A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its occurrence and any rehabilitation you have undergone. Revised 01/25/03
 
 

EMPLOYEE APPLICATION WORK HISTORY

Work References: List all your work experience beginning with your most recent job. You will be asked to explain all gaps in employment and what you were doing during that time. Include military experience, summer, part time jobs and any verifiable work performed on a voluntary basis. Please complete all appropriate items, even if you have already provided us with a resume.
 
Employer *
Address *
City * State * Zip (5 digits) *
From * To * Phone *
Pay Rate *
Manager Name *
May we contact? * Yes / No
 
Describe job duties/department *
Reason for leaving *
 
Employer
Address
City State Zip (5 digits)
From To Phone
Pay Rate
Manager Name
May we contact? Yes / No
 
Describe job duties/department
Reason for leaving
 
Employer
Address
City State Zip (5 digits)
From To Phone
Pay Rate
Manager Name
May we contact? Yes / No
 
Describe job duties/department
Reason for leaving
 
 

EMPLOYMENT APPLICATION

How were you referred to us? *
 

PROFESSIONAL REFERENCES

Name * Title * Phone *
Address *
City * State * Zip (5 digits) *
 
Name * Title * Phone *
Address *
City * State * Zip (5 digits)*
 
Please list any other work related information you think would be helpful to us in considering you for employment, such as additional work experience, accomplishments, languages and activities (Optional):
 

Applicant Acknowledgement

I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment.
 
I authorize American Home Health to investigate my employment history, credentials and to obtain any relevant information (including a criminal background check) needed to make an employment decision. I authorize AHHC to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize AHHC to disclose any of my performance appraisals, disciplinary records or skill tests for the same purposes as above. I release AHHC and any individual or entity providing information to AHHC from all liability for any damages from the disclosure of this information.
 
I also understand and agree that: Passing a medical examination and/or participating in a post-conditional offer medical screening may be required. If medical restrictions cannot be reasonably accommodated, I may not be hired, or if hired, employment may be terminated. I may be subject to pre-employment drug testing, or a drug test where a reasonable suspicion exists, or where warranted by circumstances, workplace conditions or contractual requirements.
 
I understand and agree that nothing contained in this employment application or in granting of an interview creates an employment contract between AHHC and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable β€œat will,” that I will have the right to terminate my employment at any time, and that AHHC will retain a similar right to terminate my employment at any time.
 
I understand that should I become employed by AHHC, my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of American Home Health Corporation.
 
Signature (Print your name): *
 
Pursuant to Title VII of the Civil Rights Act of 1964 (42 U.S.C. C2000d et seq.) and 45 C.F.R. part 80, section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. d794) and 45 C.F.R. part 84, and the Age Discrimination Act of 1975 (42U.S.C. d6101 et seq.) and 45C.F.R. part 91, the company adheres to an equal opportunity policy for all persons seeking admission as clients or seeking employment or for all person employed by the company. The company does not discriminate because of age, race, color, religion, military status, marital status, gender preference, sex, national origin or disability.
 
 

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