Employment Application Form

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PLEASE PRINT

Desired Position:   RN LPN HHA HMKR/Companion Live-In PT Other

Joy Bringers Home Care
(JBHC)

Providing meaningful work opportunities for home health
care professionals who are compassionate, pursue
excellence, and are reliable.

Committed to Excellent and Quality Care.

JBHC is committed to fair and equal
employment and access to home care services.

JBHC Employment Application - Page 2

PERSONAL INFORMATION

Street Address
Apt. No.
City
State
Zip
Telephone Number
Cell Telephone Number
Alternate Number
Email Address
Languages Spoken
Other Names Used for Education or Employment Purposes
Are you authorized to work in the United States?

Yes No

Have you ever worked for JBHC?

Yes No    If yes, where?

How did you learn about JBHC?

JBHC Employee Direct Mail Friend/Neighbor/Relative Internet Newspaper Radio School TV Yellow Pages Other:

Please identify the specific source (e.g., name of newspaper):

EDUCATIONAL BACKGROUND

Name of School
Address/City/State
Years Completed
Degree Received
Name of School
Address/City/State
Years Completed
Degree Received

PROFESSIONAL LICENSURE, CERTIFICATION, OR TRAINING

License
State of Issue
License Number
Expiration Date
License
State of Issue
License Number
Expiration Date
Certification
State of Issue
CPR Certified?

Yes No

Certificate Number
IV Certified?

Yes No

Expiration Date
Other:

Please specify

EMPLOYMENT INFORMATION
Please provide information on all employers for the last 5 years, starting with the most recent.

Name of Employer
Address
City
State
Zip
Telephone Number
Supervisor’s Name
Supervisor’s Telephone Number
Position Held
Employment Dates
to
Ending Pay (per hour)
Reason for Leaving
Type of Position

Full-time Part-Time Per Diem

Name of Employer
Address
City
State
Zip
Telephone Number
Supervisor’s Name
Supervisor’s Telephone Number
Position Held
Employment Dates
to
Ending Pay (per hour)
Reason for Leaving
Type of Position

Full-time Part-Time Per Diem

This section continued on page 3

JBHC Employment Application - Page 3

EMPLOYMENT INFORMATION
continued from page 2

Name of Employer
Address
City
State
Zip
Telephone Number
Supervisor’s Name
Supervisor’s Telephone Number
Position Held
Employment Dates
to
Ending Pay (per hour)
Reason for Leaving
Type of Position

Full-time Part-Time Per Diem

If additional space is needed, please request a blank sheet of paper

ASSIGNMENT PREFERENCES

Keep in mind that JBHC provides client services 24 hours a day, 7 days a week. Your flexibility is greatly appreciated.Please check the days and time of day that you would like to work:

Monday Day Evening Night
Tuesday Day Evening Night
Wednesday Day Evening Night
Thursday Day Evening Night
Friday Day Evening Night
Saturday Day Evening Night
Sunday Day Evening Night

Client Preference(s):   Pediatric Adult Geriatric Rehab Terminally ill

Are you willing to cover call-outs?    Yes No

Are you willing to work holidays?    Yes No

Please list:

Are you able to work cases where public transportation may not be available?    Yes No

Are you willing and able to work in homes with dogs?    Yes No    Cats?    Yes No

Comments:

Are you willing and able to work in homes with smokers?    Yes No

Comments:

How many miles are you willing to travel from home?   

How many hours per day are you willing to work?   

Geographic Preferences:   

Other Work Preferences:   

Please note: JBHC cannot guarantee work or give assurance that you will only be offered cases within the preferencesthat you have selected. This information will help us try to accommodate your requests.

JBHC Employment Application - Page 4

EMPLOYEE INTEGRITY INSURANCE COVERAGE SCREENING


How many years at your current address listed on page 2 of the application?    1    2    3    4    5+

Previous Address Street/Apt #
Post Office Box
City
State
Zip
How many years at this address?

How many years have you lived in the state in which you are seeking employment?    1    2    3    4    5+

Malpractice Insurance Yes No
Carrier name, if applicable
Address
Applicant Policy Number
Answer yes or no to the following questions (explain “yes” answers with the date(s) and detail(s) of each answer in the section below)
1 Have you ever worked under a different name? Yes No
2 Have you ever been bonded in a previous position? Yes No
3 Have you ever stolen?
 Yes No
4 Have you ever worked in a capacity of handling cash or cash equivalents?.
 Yes No
5 Have you ever been reprimanded, suspended, or discharged from a job due to violent behavior at work? Yes No
6 Have you ever been reprimanded, suspended, or discharged from a job due to abuse/neglect of clients or children? Yes No
7 Have you ever been investigated for suspicion of abuse/neglect of clients or children by a government agency? Yes No
8 Have you ever been involved in a lawsuit, either directly or through an employer, alleging negligence or malpractice? Yes No
9 Have you ever been sanctioned or excluded from participation in federal orstate healthcare programs or surrendered/lost your professional license for an offense that could lead to sanction or exclusion? Yes No
10 Have you ever had disciplinary action filed against your professional license or CNA/HHA certification in any state? Yes No
11 Have you ever been reprimanded, suspended, or discharged from a job for any reason? Yes No
Explain:

Applicant statement: By signing below, I verify that all information provided about my background, education, licensure, employment history, and skills is true, complete, and correct. I authorize JBHC Home Health Care to independently verifyany information provided by me in the hiring process and if hired, throughout my employment. JBHC may specifically contactany reference, learning institution, current or previous employer of mine whether disclosed in my employment application or not. I understand that any offer of employment may be withdrawn or terminated if discrepancies are found.

Witness

Office Address

6 Auer Ct, Unit G, East Brunswick, NJ 08816

Email

info@joybringersofnj.com

Phone Number

732-253-7822

Fax Number

732-317-3250

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