PERSONAL INFORMATION Date: Position Applied For: Registered NurseLicensed Practical NurseCertified Nursing AssistantDirect Support PersonnelInternship SS#: First Name: Last Name: Maiden Name: Date of Birth: Marital Status: Are you a legal citizen of the USA? YesNo Home Phone: Cell Phone: Email: Street Address: City: State: Zip: Are you currently employed: YesNo Name of Employer: Phone: Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accomodation? YesNo If yes, please explain: Are you at least 18 years old? YesNo Have you ever worked for NGHS before? YesNo Do you have a relative/friend who worked or works for NGHS? YesNo If Yes, who? LICENSES AND CERTIFICATIONS Are you Licensed/Certified for the job applied for? YesNo Name of license/certification: Issuing State: Expiration: Name of license/certification: Issuing State: Expiration: Name of license/certification: Issuing State: Expiration: Have you ever had a license/certification revoked or suspended?NoYes If Yes explain: EMERGENCY CONTACT INFORMATION Contact #1 Name: Phone: Relationship: Contact #2 Name: Phone: Relationship: AVAILABILITY Below, please list all days and times that you are available for work. *Please note that some weekends are mandatory for employment with NGHS. Date you are available to work: Desired Wage/Salary? Sunday Monday Tuesday Wednesday Thursday Friday Saturday AM AM AM AM AM AM AM PM PM PM PM PM PM PM Please list ALL counties/areas that you are willing to travel to for work: Have you ever been convicted of a felony? YesNo If Yes, state nature of the crime(s), when and where convicted and disposition of the case(s). NOTE: No applicant will be denied employment based solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, surrounding circumstances, and relevance of the offense to the position(s) applied for might and can be the primary reason for a “no” hire. Some of our clients do not speak English. Do you speak, write or understand any foreign language(s)? YesNo If Yes, What language(s) Do you understand sign language and/or can hand sign? YesNo Check Yes or No by each home care duties/tasks that you are able to perform. Ambulation YesNo Meal Preparation YesNo Assistance w/travel YesNo Medication Reminders YesNo Bathing YesNo Personal Hygiene YesNo Body Care YesNo Positioning YesNo Dressing YesNo Shopping/Errands YesNo Eating (assistance w/eating) YesNo Supervision YesNo Grooming YesNo Toileting YesNo Housework YesNo Transferring YesNo Laundry YesNo Telephone Assistance YesNo Meal Planning/Diets YesNo Companionship YesNo Diaper Change/ Incontinent Care YesNo Perineal Care YesNo EDUCATION BACKGROUND All positions at NGHS require a minimum educational level of a High School Diploma or equivalent. High School Name: City: State: Did you graduate? YesNo College Name: City: State: Did you graduate? YesNo Other Institute: What machines or equipment have you operated that relates to the position you have applied for? Are there any skills, experience or other qualifications that you feel would assist you in performing the duties of the position you have applied for? EMPLOYMENT HISTORY EMPLOYER 1 Employer 1: Phone: Commencement Date: Departure Date: Reason for Departure: Supervisor’s Name: Supervisor’s Phone: Duties: May we contact this employer?YesNo (If No, please explain): EMPLOYER 2 Employer 2: Phone: Commencement Date: Departure Date: Reason for Departure: Supervisor’s Name: Supervisor’s Phone: Duties: May we contact this employer?YesNo (If No, please explain): EMPLOYER 3 Employer 3: Phone: Commencement Date: Departure Date: Reason for Departure: Supervisor’s Name: Supervisor’s Phone: Duties: May we contact this employer?YesNo (If No, please explain): MILITARY EXPERIENCE Do you have any military experience? YesNo (If Yes, please include branch and highest rank): Were you dishonorably discharged? YesNo (If Yes, please explain): REFERENCES List three persons not related to you who have knowledge of your work performance within the last three years. Name: Phone: No. of Years Acquainted: Name: Phone: No. of Years Acquainted: Name: Phone: No. of Years Acquainted: If you are applying for a position that requires driving, please complete this section Do you have a valid driver's license? YesNo (If Yes, provide details below): Lincense #: State: Has your driver’s license been suspended, revoked within the past 10 years? YesNo (If Yes, state when and why): If you are selected for an interview, you are required to present a copy of your driving record that is not more Than four (4) weeks old. After being hired, a copy of this driving record will be placed into your personnel file. An annual update record is required. FALSE INFORMATION GIVEN OR IMPLIED ON AN APPLICATION IS GROUNDS FOR IMMEDIATE DISMISSAL WITHOUT FUTHER NOTICE. In exchange for the consideration of my job application by NGHS, Inc., I agree that neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, and policy statements. The like as they may exist from time to time, or other company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of NGHS, Inc. or otherwise to change in any respect the employment-at- will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Director or the company. Both the undersigned and the Director may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I hereby state that all information provided is accurate and may be verified by you. I agree that I may be discharged if NGHS at any time learns of falsification or material omission in the information provided on this application form and related documents. NGHS may contact my former employer in connection with the consideration of my employment with them. I hereby release NGHS, its affiliates, successors and assign, and all references from any liability that might be claimed because of information provided by such references. I agree that I will follow all company policies, rules, procedures, and other directions pertaining to my employment. I understand that NGHS reserves the right to add, change, and/or delete any policies, procedures, work rules, and/or benefits at any time. NO CONSIDERATION WILL BE GIVEN TO ANYONE WHO DOES NOT SIGN THE ABOVE STATEMENT Applicant’s Signature: Date: New Generation Health Services, Inc. is committed to the principle of equal employment opportunity for all applicants, and to providing them with a work environment free of harassment and/or discrimination. All employment decisions are based on each applicant’s qualifications, training, experience, and the company’s need without regard to race, religion, sex (including pregnancy), origin, age, disability, sexual orientation, gender, marital status, or any other status protected by all applicable laws. CRIMINAL BACKGROUND SCREENING CONSENT AUTHORIZATION I fully understand that I must submit a criminal background check prior to being hired with NGHS. For purposes of evaluating your application for employment purposes or volunteer service, NGHS, its affiliates and/or agents may conduct and obtain a criminal background history check. Depending upon the position for which you are applying, your criminal background report may be grounds for a “no” hire. By signing this form you authorize NGHS to obtain a criminal background at any time during your employment with NGHS. I also truthfully state that I have never abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct. Applicant Signiture: Date: Thank you for completing our application packet and interest in pursuing employment with NGHS.
