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PERSONAL DATA

(OFFICE USE ONLY)

(OFFICE USE ONLY)

JOB INTEREST

Please check the specialty area(s) that best match(es) your experience / education and interested

Homecare Medical / Surgical IV Therapy
Intermittent Care Private Duty Hospice
Rehabilitation Pediatrics/Maternal Child Supplemental Staffing
Residential Care Nursing Home Hospital
Geriatric Psychiatric Homemaking

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Full Time (32 hours per week average)
Part Time ( less than 32 hours per week average)
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Nights Visits Only
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EDUCATION

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High School Diploma Associate Bachelors Masters
LICENSE / CERTIFICATIONS / EXAMINATIONS

GENERAL INFORMATION

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WORK HISTORY

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Employment Dates

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Employment Dates

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Employment Dates

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In accordance with Title VI of the Civil Rights Act of 1964 and its implementing regulation, 1 Amazing Home Health Care LLC., is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRIMINATE AGAINST RACE, COLOR, SEX, CREED, NATIONAL ORIGIN ORCOMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI. In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation I Amazing Home Health Care LLC. WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP. In accordance with the Age Discrimination Act of 1975 and its implementing regulation, 1 Amazing Home Health Care Services LLC. WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision of services, unless age is a factor necessary to the normal operation or the achievement of any statutory objective. In accordance with the Americans with Disabilities Act of 1992 (42 USC $I2101) and its implementing regulations, (private employers with more than 25 agency personnel),1 Amazing Home Health Care LLC ., WILL NOT, DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment that substantially limits a major life activity, or for which them is a record of impairment or which causes the individual to be regarded as impaired.


This information that I have given is true and accurate to the best of my knowledge.

REFERENCE CHECK

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ASSESSMENT OF WORK ETHIC

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If you answered "no" to rehire eligibility or you possess any other pertinent information, positive or negative in regards to the named applicant's ability, character and/or integrity, the signature below gives you the authority to share the information/ Please describe:

I hereby authorize any person, company, or organization to furnish answers to the questions regarding my employment record.

I hereby release all liability created by this inquiry into my employment record, by the communication of the requested information, or by any action taken based on that information and from any other claim for relief of any kind and from any and all causes of action which I might otherwise assert based upon said inquiry, communication, or action.

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