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America's Health Care, LLC is an equal opportunity employer!


Personal Information
First Name		Last Name
Address 1:		Address 2:
City		State
Zip
DOB	[mm/dd/yyyy]	SSN
Gender
Email		Phone

Background Information
If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?	Yes No
Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?	Yes No
If yes, state the nature of the crime(s), when and where convicted and the dispostion of the case:

Emergency Contact Info
Name		Phone
Address

Professional Information
Profession		Date Available	[MM/DD/YYYY]
Specialty		Work Preferences (check all that apply):	Permanent Per Diem Part-Time Per Diem Full-Time Per Diem

Education, Training and Experience
High School
School Name		School Address
Years Completed		Did you graduate?	Yes No
Degree or Diploma
Vocational / Business
School Name		School Address
Years Completed		Did you graduate?	Yes No
Degree or Diploma
College/ University
School Name		School Address
Years Completed		Did you graduate?	Yes No
Degree or Diploma
Graduate
School Name		School Address
Years Completed		Did you graduate?	Yes No
Degree or Diploma

Are you licensed / certified for the job applied for?	Yes No	Professional License No:
Expiration Date:		Type of License

Professional License No:		Expiration Date:
Type of License
Has your license ever been supsended or revoked?		Yes No
If yes, state reason(s), date of revocation or suspension and reinstatement:

Employment History
List below all present and past employment starting with your most recent employer (previous 5 years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.
#1
From:		To:
Employer		Job Title
Address
Duties		Ending Salary
Supervisor		Supervisor Phone
Reason for leaving

#2
From:		To:
Employer		Job Title
Address
Duties		Ending Salary
Supervisor		Supervisor Phone
Reason for leaving

#3
From:		To:
Employer		Job Title
Address
Duties		Ending Salary
Supervisor		Supervisor Phone
Reason for leaving

#4
From:		To:
Employer		Job Title
Address
Duties		Ending Salary
Supervisor		Supervisor Phone
Reason for leaving

Employment References - Minimum TWO Required
Company Name
Address
City		State		ZIP
Contact Person and Title		Phone		Fax
Company Name
Address
City		State		ZIP
Contact Person and Title		Phone		Fax

Additional Information
How did you hear about America's Health Care?
Who referred you to America's Health Care?
Who is your contact / recruiter at America's Health Care?
Your Resume
Upload Your Resume:

Certification
I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by America's Health Care, LLC unless I have indicated to the contrary. I authorize the references listed above to provide America's Health Care , LLC any and all information concerning my previous employment and any pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to America's Health Care, LLC as well as from the use or disclosure of such information by America's Health Care, LLC or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification,or material omission of information on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered. If I am hired, I understand that I am free to resign at any time, with or withoutprior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and withoutprior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for anyspecified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant's identity and legal authority to work in the U.S.

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