Employment Application Step 1 of 4 25% Onboarding Memorandum Nursing License for maryland: Documents required with this application (All) Check if attached Thoroughly completed employment application Current Professional License (Signed), if any Current CPR card/First Aid (Signed) PPD/Chest X-Ray /Medical Employment Eligibility Verification (Form I-9) Driver’s License/ State Issue ID card (Signed) Two employment reference forms or letter (phone # included) One personal reference form or letter (phone # included) Copy of Social Security Card (Bring original signed copy to interview) One year of experience working in the field Background Check (a must) Any other information you have for employment If you do not have all the documents above, please tell us when it will be available:Your Personal InformationDate of Application MM slash DD slash YYYY Name First Middle Last Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email Address Your PhoneSSNDate of birth MM slash DD slash YYYY Are you a citizen of the United States No Yes Are you eligible to work in the United States Yes No If you are under age 18, do you have an employment/age certificate? No Yes Have you ever been convicted of a misdemeanor or felony? No Yes If yes, please explain the circumstances of the conviction: Position You're Applying ForPosition You're Applying For Registered Nurse Licensed Practical Nursing (LPN) Certified Medical Technician Certified Nursing Assistant (CNA) Geriartic Nursing Assistant (GNA) UA/CCA Previous EmploymentEmployer 1Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Positioned heldEmployer PhoneReason for leavingMay We Contact This Employer?YesNoEmployer Email Employer 2Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Positioned heldEmployer PhoneReason for leavingMay We Contact This Employer?YesNoEmail Employer 3Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Position heldEmployer PhoneMay we contact ths employerYesNoReason for leavingEmail Please indicate all relevant experience, skills and work history that relate to the job description of which you have applied. Available Days/Times (in HH:MM format) Day Sunday Date MM slash DD slash YYYY Day Monday Date MM slash DD slash YYYY Day Tuesday Date MM slash DD slash YYYY Day Wednesday Date MM slash DD slash YYYY Day Thursday Date MM slash DD slash YYYY Day Friday Date MM slash DD slash YYYY Day Saturday Date MM slash DD slash YYYY Education And TrainingHigh School Name:Date MM slash DD slash YYYY Diploma received Yes No College/Training SchoolDate MM slash DD slash YYYY Diploma received Yes No Professional Training/Qualifications with dates and levels obtained:Date MM slash DD slash YYYY Cerification/License ObtainedSkills Can you do vital signs? Yes No Can you do a neurological assessment? Yes No Can you chart nurses’ notes? ? Yes No Can you give intramuscular medications? Yes No Can you do catheter care? Yes No Can you give IV medications? Yes No Can you start IV’s? Yes No Can you access patients for admission? ? Yes No Can you discharge patients? Yes No Can you set up oxygen for patients? Yes No Have you had CPR? Yes No Do you have intensive care experience?? Yes No PreferenceAre you a licensed driver? Yes No Will you work shifts at a hospital? Yes No Will you travel 30 minutes one way? Yes No Will you work shifts at a nursing home? Yes No Will you work every other weekend? Yes No Will you work private duty cases? Yes No In which areas have you had experience? Medical Surgery OB/GYN Oncolology Geriatric Emergency Room Medical History Skills What absences due to illness have you had from work for the past two yearsDo you have any illness that will prevent you from performing the duties of the position of which you have applied?Can you lift or push a weight of seventy pounds? Yes No Have you had any special traininglist special training and or certificationsDo you have any handicaps?. If so explainHow many hours a week do you wish to work?Character References Please list three references of which we may contactNameRelationshipYears of AffiliationPhoneEmail CommentsNameRelationshipYears of AffiliationPhoneEmail CommentsNameRelationshipYears of AffiliationPhoneEmail CommentsDeclaration By signing below, I, , hereby certify that all information included in the above application is true and valid to the best of my knowledge. I also understand that misrepresentation or falsification of the information provided above will result in my immediate disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery. SignatureDate MM slash DD slash YYYY More About YouAre you are a US citizen? Yes No Are you eligible to work in the United States? Yes No If you are under age 18, do you have an employment/age certificate? Yes No Have you ever been convicted of a misdemeanor or felony? Yes No Employee Emergency Information Emergency Contact 1 First Last Email PhoneRelationshipEmergency Contact 2 First Last Email PhoneRelationshipEmergency Contact 3 First Last Email PhoneRelationshipTell Us About YourselfUpload Your ResumePlease upload multiple documents including any certifications and your resume in pdf, doc or .docx format. Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 25 MB. Hepatitis B Immunization Consent/RefusalYes I want to receive the Hepatitis B vaccine Yes I want to receive the Hepatitis B vaccine I read the information given to me about Hepatitis B virus and Hepatitis B vaccine and I had the opportunity to ask questions. My questions were answered. I want to participate in the vaccination program. I understand this includes three injections at prescribed intervals over a 6-month period. I understand that there is no guarantee that I will become immune to Hepatitis B and that I might experience an adverse side effect as the result of the vaccination.1st DoseDate given MM slash DD slash YYYY Lot # administered ByNext due date MM slash DD slash YYYY 2nd DoseDate given MM slash DD slash YYYY Lot # administered ByNext due date MM slash DD slash YYYY 3nd DoseDate given MM slash DD slash YYYY Lot # administered ByNext due date MM slash DD slash YYYY No, I do not want to receive the Hepatitis B vaccine. I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring Hepatitis B virus (HBV). I was given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to me. However, I declined Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at an increased risk of acquiring Hepatitis B, a serious disease. If in the future I want to be vaccinated with the hepatitis B vaccine, I understand that I can receive the vaccine series at no charge to me.Confidential Agreement(Required)READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT I agree that except at the request and for the benefit of Ageless Healthcare LLC I will not disclose to anyone or use for my own purposes any of Ageless Healthcare, LLC confidential or proprietary information, either during or after my employment. I understand and agree that Ageless Healthcare, LLC bidding, costs, pricing and marketing information and techniques, customer names and information, and employee name and information are confidential and proprietary to Home Health Care, LLC. I certify that this application contains no willful misrepresentation or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I authorized Ageless Healthcare, LLC to contact all sources to verify the information on this application. I understand that any falsification, misrepresentation or fraudulent information provided by me in connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate discharge.I understand that this application is not a contract of employment. I authorize and request my former employers, references, and educational institutions which have information about me, to give Ageless Healthcare, LLC any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and release such former employers, references, and educational institutions from any liability or claim relating to such release of information and opinions. I also authorized and requested federal, state, and local governmental agencies to release to Ageless Healthcare, LLC any information requested, concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original. I agree to the terms and conditions.Conflict of Interest I acknowledge that I have read the company policy statement concerning conflict of interest and I hereby declare that neither I, nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company that would constitute a violation of that company policy. Furthermore, I declare that during my employment, I shall continue to maintain my affairs in accordance with the requirements of said policy.Signature(Required)Date MM slash DD slash YYYY Caregiver Consent FormName First Last Date of birth MM slash DD slash YYYY Social Security #TelephoneI hereby consent to provide care for clients of Ageless Healthcare, LLC. and I hereby acknowledge that such consent will remain in effect unless and until I cancel such consent writing. I hereby acknowledge and confirm that I am mentally capable of giving informed consent to the provision of the care and am not subject to duress or undue influence. I HEREBY ACKNOWLEDGE AND UNDERSTAND THAT, BY SIGNING THIS VOLUNTARY CAREGIVER CONSENT FORM, I AM GIVING INFORMED CONSENT TO PROVIDE Ageless Healthcare, LLC AND CANNOT BRING A TORT OR OTHER SIMILAR ACTION AGAINST Ageless Healthcare, LLC UNLESS THE ACTION OR OMISSION OF Ageless Healthcare, LLC CONSTITUTES WILLFUL OR WANTON MISCONDUCT. Upon signing this agreement, I agree that I will not employ any client from Ageless Healthcare, LLC. without the due consent of Ageless Healthcare, LLC. Ageless Healthcare, LLC preserves the right to sue the caregiver for up to $10,000.00 if the caregiver is employed directly or indirectly by the client. Signature(Required)Date MM slash DD slash YYYY