List all previous employers, beginning with the most recent. Include all requested information on an additional page if necessary and label with your name.
General Employment Questions
Educational History
High School
College or University
Other(specify)
Professional Licenses, Registrations, And/Or Certifications
NOTE: FOR ANY POSITION REQUIRING RESITRATION, LICENSURE, OR CERTIFICATION, ORIGINAL DOCUMENT MUST BE PROVIDED
Specialized Skills
Employment Acknowledgement
I understand that any false statements or material omissions made as a part of this application will disqualify me from further consideration for employment and, if discovered later, will be grounds for discharge. I also understand that any offer of employment is contingent upon the results of a pre-employment medical examination, drug screen, criminal background check and reference check. I authorize my former employers to release all information concerning my employment. I further authorize the release of any such information during or after my employment, without prior notification. This authorization releases the aforesaid parties and Direct Home Healthcare Services, Inc. (DHHSI) from any liability for the collection and reporting of this information. Direct Home Healthcare Services, Inc. does not discriminate in hiring or employment on the basis of sex, color, marital status, religion,sexual orientation, national origin, age, disability, military status, or any other protected category. No question on this application is intended to secure information to be used for such discrimination. I understand that if I am employed by DHHSI, my employment is “at will” and may be terminated by me or by DHHSI at any time with or without cause, for any reason. No one other than the President of DHHSI has the authority to enter into an agreement contrary to the foregoing and any such agreement must be in writing and signed by both the President and me.
Clear
Reference Form
Section A: Candidate, please complete Section A only and forward directly to:
Section B: (To be completed by Direct Home Healthcare Services, Inc.)
Section C: (To be completed by Employer Direct Home Healthcare Services, Inc. Thank you for completing this form as it assists us in ensuring that all professional accepted into our program are of the highest caliber. Your responses will remain in the strictest confidence.)
Initial Competency Checklist
RN LPN
Date and RN's signature indicates that the nurse has been checked off on the procedure.
Select a country first.