* = Required Information

Personal Data

Emergency Contact Information

Job Information

RN PT LP/VN CNA OT PTA Clerical Other
Please list the number'of years you have experience in each area (min. 1 year exp.) and are clinically competent to work:
Burn ENT Pediatrics Detox/Drug Rehab
L & D Rehab Telemetry Post Partum
MICU Nursery Psychiatry Orthopedics
NICU Dialysis Stepdown Mother/Baby
PACU Geriatric Oncology Recovery Room
SICU Pedi ICU Neurology Operating Room
CCU Med/Surg Open Heart Emergency Room
Other Other Other Other
Hospital Hospice Nursing Home
Rehab Private Duty Assisted Living / Residential Treatment
Spanish French German Other
Full-time Part-time Contract Travel
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays available to work
Yes No

Certifications: Check all applicable certifications and enter expiration date:

ACLS
BCLS
CPR
PALS
Other
IV
NALS

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Yes No
Yes No
Yes No

Yes No
Yes No
Yes No

Yes No
Yes No
Yes No

Additional Information:

Yes No
Yes No
Yes No
Newspaper
Trade Publication
Job Fair/Open House
Internet Site
Company Employee - Name
I understand that I must report all accidents to my immediate supervisor and to Alliance Home Health Services - - No MATTER HOW SLIGHT Yes

I also understand that l must wear all required personal protection equipment (PPE).
The penalty for not wearing PPE is disciplinary action. up to and including termination. Yes

ACKNOWLEDGMENT (Please read carefully and sign)



In signing this application, 1 certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may Jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Alliance Home Health Services permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions l have attended, credit agencies, all references, and any other persons to answer all questions asked by Alliance Home Health Services with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Alliance Home Health Services may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. l release Alliance Home Health Services, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Alliance Home Health Services, I agree to abide by all rules and regulations, which i understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Alliance Home Health Services or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Alliance Home Health Services, at any time, can constitute a contract of employment. No representative or agent of Alliance Home Health Services, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Alliance Home Health Services is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Alliance Home Health Services against any and all liability and responsibility associated with his or her professional duties. The Professional maintain his or her license as required by law, professional liability coverage and other responsibilities as found understate prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

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