Certified Nursing Assistant (CNA)/ Home Health Aide (HHA)

step 1

Elite Care Management

Complete Home Care Services

Federal and State laws prohibit discrimination in employment because of race, religion, age, gender, sexual orientation, disability (mental or physical),communicable disease, or place of natural origin, veteran status, and citizenship status. We are an equal opportunity employer.

Applicants ay request accommodations needed to apply for work.

Please upload your most current resume. File types accepted pdf,doc,docx. File size limit: 5Mb

Name (required)

Address (required)

City/State/Zip (required)

Date of Birth(required)

Home Phone

Cell Phone (required)

Email (required)

Emergency Contact

Position applying for (required)

Rate Desired (required)

Rate per Hour(required)

Are you applying for?
Full TimePart Time

How did you hear about us?
NewspaperFriendClientOther

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step 2

Are you a U.S. Citizen or Authorized to work in the U.S?
YesNo

Have you ever been employed under another name?
YesNo

Have you ever applied to this company before?
YesNo

Have you ever been convicted of a crime within the last 7 years?
YesNo

Education Information

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step 3

Employment Information

Are you currently employed?
YesNo

May we contact your present employer?
YesNo

Please provide the following requested information regarding your employment history for up to the last 10 years. Include military service assignments and volunteer activities. You may exclude organization names that indicate race, color, religion, gender, national origin, ancestry, age, disability or other protected status.

Are you fluent in any other languages?

YesNo

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step 4

Professional References

(Required) Please provide the names, addresses, and phone numbers for three persons not related to you who can provide information relative to your ability to work.

Employment Availability

RNLPNCNAOther

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step 5

Please Read Carefully and in Full

"My signature indicates that I understand and agree to all of the conditions listed below"

I certify that all of the foregoing statements are true and correct to the best of my ability. I understand that misrepresentations or omission of facts is cause for denial of employment or dismissal.

I understand that inquires will be made of former employers and references regarding work performance and of educational institutions regarding transcripts. I release from all liability all persons, companies and corporations, and educational institutions supplying such information. Additionally, I will indemnify and hold harmless the company and its officers, directors, employees, and agents against any liability, which might result from making such an investigation.

I understand that if employed at Elite Care, my employment is at will and that I or the company can terminate the employment relationship, with or without cause, at any time, with or without prior notice

Applicant Signature

Date

Signature: (use your mouse to sign below)

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