Job Seeker / Referrals

Interested in working with us?

National Home Health Care LLC is dedicated in providing optimal care to our patients. If you are a caring and dedicated health care provider, we are happy to welcome you in joining our compassionate and respectful team.

Application form

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential. Fill in the form below.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home / Cell

(###)

###

####

Business Phone

(###)

###

####

Emergency Contact (person not living with you)

Have you ever applied for employment with this Agency?

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

How did you learn of our organization?

Are you willing to work

Position applying for

Education - College

Please list: Name, Location, Course of Study and Degree /Diploma

Education - Vo-Tech or Trade

Please list: Name, Location, Course of Study and Degree /Diploma

Education - High School

Please list: Name, Location, Course of Study and Degree /Diploma

Education - Other

Please list: Name, Location, Course of Study and Degree /Diploma

Employment - last 5 years employment history, starting with most recent:

1. Please list: Company Name, Address, Phone, Dates of Employment, Starting Pay

Employment

2. Please list: Company Name, Address, Phone, Dates of Employment, Starting Pay

Employment

3. Please list: Company Name, Address, Phone, Dates of Employment, Starting Pay

Employment

4. Please list: Company Name, Address, Phone, Dates of Employment, Starting Pay

Employment

5. Please list: Company Name, Address, Phone, Dates of Employment, Starting Pay

Was your last name different from your present name during the above listed jobs?

If yes, what was your name?

Are you currently employed?

Do you have reliable transportation?

Professional References

List 3 Persons who can furnish information about job performance. Include: Name, Phone, Fax, Address

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

If yes, describe in full

Conviction will not necessarily disqualify an applicant from employment

Are you capable of performing the job set forth in the description?

If no, which job requirement can you not meet?

Credentials/Specialized Skills & Qualifications/Equipment Operated

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

Please check to confirm the following:

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 complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing the same to the Agency.

I understand and agree that if hired, my employment is for no definite period and may, regardless of date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

I understand and agree that this is my electronic signature*

Name

First Name

Last Name

Date

YYYY

Patient Referral

Please download the referral form and fax it back to us on: 781-436-3458

Download