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.
* = Required Information
PERSONAL
Yes No
Yes No
Day Shifts Night Shifts
Monday Tuesday Wednesday
Thursday Friday Saturday
Sunday
LPN RN Therapist CNA

Skills:

Procedure Y/N Years Experience
Trachs
Peds
Geri
Home Care
Visits
Shifts
Wound Care
Feeding Tubes
TPN (RN ONLY)

 

Procedure Y/N Years Experience
PCT Cardio ICU
Adolescents
Psych
Wound Vac
Prenatal
Dementia
Age Preference
Vents
LPN IV Certification? (Please provide copy)
EDUCATION
EMPLOYMENT
List the last five years employment history, starting with the most recent employer.






Yes No
Yes No
Yes No
PROFESSIONAL REFERENCES
Persons who can furnish information about job performance
GENERAL
Yes No
Yes No
CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

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 GROUND FOR DISMISSAL

I Authorize complete investigation of all statements contained herein and hereby 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 arid may, regardless of the 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.

DISCLAIMER
Nondiscrimination and Equal Employment Opportunity

It is the policy of Preferred Touch Home Care to ensure equal employment opportunity without discrimination or harassment on the basis of race, color, religion, sex, sexual orientation, gender identity or expression, age, disability, marital status, citizenship, genetic information, or any other characteristic protected by law. Preferred Touch Home Care prohibits any such discrimination or harassment.

I understand that I will not be discriminated against based on race, color, religion, sex, sexual orientation, gender identity or expression, age, disability, marital status, citizenship, genetic information, or any other characteristic protected by law.

Voluntary Disclosure of Disability

Assurance of Confidentiality
The voluntary information collected for this form will be treated confidentially.

Definition of a Disabled Individual
The term Disabled Individual shall mean

An individual who: 1) has a physical or mental impairment which substantially limits one or more of such individual’s major life activities; or 2) has a record of such impairment; or 3) is regarded as having such an impairment.

Impairments include, but are not limited to:

  • Blindness
  • Deafness
  • Cancer
  • Diabetes
  • Epilepsy
  • Autism
  • Cerebral palsy
  • HIV/AIDS
  • Schizophrenia
  • Muscular dystrophy
  • Bipolar disorder
  • Major depression
  • Multiple sclerosis (MS)
  • Missing limbs or partially missing limbs
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder
  • Impairments requiring the use of a wheelchair
  • Intellectual disability

A disabled individual is considered “substantially limited" if he or she is likely to experience difficulty in securing, retaining or advancing in employment or education because of a disability.

Disclosure of Disability
I am a disabled individual as defined above on this form
I am not a disabled individual as defined above on this form
I wish not to disclose this information at this time
Voluntary Self-Identification of Protected Veteran Status

Assurance of Confidentiality
The voluntary information collected for this form will be treated confidentially.

Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act, In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service.For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed, please indicate by checking the appropriate box below.

Please check all that apply.

Veteran status
Disabled Veteran - 1) a veteran of the U.S. military, ground, naval, or air service who is entitle to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans' Affairs;, or 2) a person who was discharged or released from active duty because of a service connected disability.
Recently Separated Veteran - a veteran during the three-year period beginning on the date of such Veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
Active Duty Wartime or Campaign badge Veteran - a veteran who served on active duty in the U.S. military, ground, navel, or air service during a time of war or in a campaign or expedition for which a campaign badge has been authorized under the laws of the administered by the Department of Defense.
Armed Forces Service Metal Veteran - a veteran who, while serving on active duty in the U.S. military, ground, navel, or air service, participated in a U.S. military operation for which an Armed Forces service metal was awarded pursuant to Executive Order 12985.
I do not identify as a protected veteran as outlined in the options above.
I wish not to disclose this information at this time.
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