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First Name
Last Name
Email
Phone
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Date of Application
How did you hear about this position?
What days are you available for work?
What hours or shift are you available for work?
If needed, are you available to work overtime?
On what date can you start working if you are hired?
Do you have reliable transportation to and from work?
Salary desired:
Have you ever applied to or worked for Loving Hearts & Hands Health Agency before? Yes No If yes, when?
YES
NO
Do you have any friends, relatives, or acquaintances working for Loving Hearts & Hands Health Agency
YES
NO
Are you 18 years of age or older?
YES
NO
Are you a U.S. citizen or approved to work in the United States?
YES
NO
What document can you provide as proof of citizenship or legal status?
Will you consent to a mandatory controlled substance test?
YES
NO
Do you have any condition which would require job accommodations?
YES
NO
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
YES
NO
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Please list below the skills and qualifications you possess for the position for which you are applying:
(Note: Loving Hearts & Hands Health Agency complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional. )
High School
College/University
Vocational School/Specialized Training
Military: Are you a member of the Armed Services?
What branch of the military did you enlist?
What was your military rank when discharged?
How many years did you serve in the military?
What military skills do you possess that would be an asset for this position?
(Previous Employment)
Employer Address:
Employer Telephone:
Dates Employed:
Reason for leaving:
(Employer Name)
References Please provide 2 personal and professional reference(s) below:
AT-WILL EMPLOYMENT The relationship between you and the Loving Hearts & Hands Health Agency is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Loving Hearts & Hands Health Agency. No representative of Loving Hearts & Hands Health Agency has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.
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