Desired Position: RN LPN HHA HMKR/Companion Live-In PT Other
PERSONAL INFORMATION
Yes No
Yes No If yes, where?
JBHC Employee Direct Mail Friend/Neighbor/Relative Internet Newspaper Radio School TV Yellow Pages Other:
EDUCATIONAL BACKGROUND
PROFESSIONAL LICENSURE, CERTIFICATION, OR TRAINING
Please specify
EMPLOYMENT INFORMATIONPlease provide information on all employers for the last 5 years, starting with the most recent.
Full-time Part-Time Per Diem
This section continued on page 3
EMPLOYMENT INFORMATIONcontinued from page 2
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:
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
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.
EMPLOYEE INTEGRITY INSURANCE COVERAGE SCREENING
How many years at your current address listed on page 2 of the application? 1 2 3 4 5+
How many years have you lived in the state in which you are seeking employment? 1 2 3 4 5+
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 I understand that any offer of employment may be withdrawn or terminated if discrepancies are found.
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