CAREERS | Abigael Home Health

EMPLOYMENT APPLICATION

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated

throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

PERSONAL INFORMATION

Today's Date:

Position Applied For:

Last Name:

First Name:

Phone:

Email:

Current Address:

Emergency Contact Name:

Emergency Contact Number:

Relationship:

Make, Model & Year of Your Vehicle:

Auto Insurance Policy #:

Expire Date:

Applied here before?

Yes

No

Worked here before?

Yes

No

If Yes When:

How did you hear about Abigael Home Health Agency?:

Have you have been given a copy of the job description for the position for which you have applied to review:

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?:

Why are you interested in employment with us?:

As a condition of employment all employees must be “Bondable” & “Insurable”. Are you at least 18 years of age?

List states and counties of residence for the past seven years:

Have you had any moving traffic violations?

Yes

No

If Yes When:

Have you been charged/convicted of a felony and/or misdemeanor/or served time?:

If Yes When:

Incident / City / Charge:

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? :

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked. What date are you available to begin work?

Please indicate all areas in which you are willing to work or for which you have a preference?

(North Broward)

(South Broward)

(East Broward)

(West Broward)

Please indicate the types of services which you are willing to provide: (for HHA/CNA only)?

Are you willing to provide service to a client with a pet?

Yes

No

Are you willing to provide service to a client that smokes?

Yes

No

This is a checkbox.

EDUCATION LEVEL:

High School

Vocational/Technical

College/University

For employment, our minimum education requirement is either a GED or High School diploma. Provide Your School Name, City, State, Major/Subject, # Yrs Attended:?

Graduate?

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

MOST RECENT EMPLOYER: Name, Address and Phone Number:

Are you currently working for this employer?

Yes

No

If yes, may we contact?

Driver's License

Work Authorization

Social Security Card

Certificate or License

Physical

CPR Card

Level 2 Background

Education Certificate

Resume

info@abigaelhomehealth.com

acha LICENSE #: 299995703

Book Free Consultation: (954) 605-5077

EMPLOYMENT APPLICATION