Job Application "*" indicates required fields Thank you for considering Assured Home Healthcare Inc. for employment. This application is available upon request from our office location in person, email attachment, or downloaded from our website. Please print the application, if obtained electronically, and completely fill out the application in black ink or typed print and sign. Submit your application via in-person to our office location, mail, fax, or as an email attachment, if applicable. You can submit your resume along with this application as well.Employment InformationLast Name* First Name* Middle Name How did you hear about us? Main Contact Number*Email Address* Current Residential Address* Street Address 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 Are you a U.S. Citizen or immigrant legally authorized to work in the United States?* Yes No Professional Licenses, Registrations, and/or CertificationsType State Issued Expiration Date Number StatusActiveExpiredOtherType State Issued Expiration Date Number StatusActiveExpiredOtherOther licenses, registrations, and/or certifications; or area of specialization or major interestSpecialty certifications, if anyCPR certified* Yes No List health care setting(s), business, computer programs, or health equipment used or experienced with:Previous Work ExperienceJob Title From To Immediate Supervisor Last Salary Employer City / State PhoneDescription of dutiesReason for leavingJob Title From To Immediate Supervisor Last Salary Employer City / State PhoneDescription of dutiesReason for leavingJob Title From To Immediate Supervisor Last Salary Employer City / State PhoneDescription of dutiesReason for leavingJob Title From To Immediate Supervisor Last Salary Employer City / State PhoneDescription of dutiesReason for leavingEducationSchool Graduate College High School NameCourse of StudyList degree or diplomaOther colleges/schools, other special courses and/or training:NoticeREFERENCES may be asked upon request.Acknowledgements:* CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOWI understand that my application process is subject to approval for employment and will be under consideration due to my qualifications, criminal history check nationally and in all state counties ever resided, sex offender searches, and any risk for the reasons Assured Home Healthcare, Inc. follows under federal, state, and local laws and codes in accordance to their company and employment policies. As of June 30, 2010; Indiana Code 16-27-2-4 Section 5 states in the following: home health agencies in Indiana as Assured Home Healthcare, Inc. may not employ a person to provide services in a patient’s temporary or permanent residence if that person’s limited criminal history, national criminal history background check, or expanded criminal history check indicates that the person has been convicted of (1) rape (IC 35-42-4-1), (2) criminal deviate conduct (IC 35-42-4-2), (3) exploitation of an endangered adult (IC 35-46-1-12), (4) failure to report battery, neglect, or exploitation of an endangered adult (IC 35-46-1- 12), (5) theft (IC 35-43-4) if the conviction for theft occurred less than ten (10) years before the person’s application date, a felony that is substantially equivalent to a felon listed in (A) subdivisions (1) through (4); or subdivision (5), if the conviction for theft occurred less than ten (10) years before the person’s employment application date; for which the conviction was entered in another state. I understand that an offer of employment would be subject to my satisfactorily passing a physical examination. I consent to and will obtain a physical examination by a physician or nurse practitioner at that time and at any future time. I understand that I may be required to satisfactorily complete an alcohol/drug screening as a condition of employment. I understand that the Agency is a health care provider and may have a no-smoking policy and I agree to comply with its requirements. I understand that my employment can be terminated at any time and for any reason, at the option of either the facility or myself. I understand that no one has the authority to enter into any agreement for employment for any specified period or to make any agreement contrary to the foregoing, except for a written employment agreement signed by and administrative representative of this Agency. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me form further consideration for employment and may result in discharge even if discovered later. I hereby authorize and request without reservation any persons, schools, my current and previous employer(s), and organizations named in this application (and accompanying resume, if any), as well as police department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about me, to provide Assured Home Healthcare, Inc. and all its affiliates with any relevant background information in their possession regarding me, in order my employment qualifications may be evaluated, and release all such persons from any liability regarding the provision or use of such information.Please attach resume with Job Experience and ReferenceMax. file size: 256 MB.Signature Reset signature Signature locked. Reset to sign again Δ