a division of
Home Health and Support Services, Inc.
Lori’s Angels Employment Application
Lori’s Angels
223 Route 61 South
Schuylkill Haven, PA
17972
1-877-264-3505
___________________________
PERSONAL
INFORMATION Today’s Date
_________________________________________________ ___________________________
Name:
Last First Middle Social Security Number
_________________________________________________ ___________________________
Address
Home
Telephone Number
_________________________________________________ ___________________________
City State
Zip Code Cell Phone /
Pager Number
_____________________________
Are you over
the age of 18? Yes No Nursing
License #
Are you a
If no, do you
have the legal right and necessary documents ___________________________
to work in the
___________________________
EMPLOYMENT
INFORMATION
Position
Desired ______________ Part-time Full-time Shift
Preference ___________
Salary Requirement
________________________ Date available for work _________________________
Do
you possess a valid driver’s license? Yes No
Driver’s License # __________________
Do
you have your own transportation? Yes No
Have
you applied here before?
Yes No If
so, when? _______________________
How
were you referred to us?
Classified ad Where did you see ad? ___________________________
An agency/registry employee Please
give us their name:_________________________
Other Please
tell us: __________________________________________________________________
QUALIFICATIONS & EXPERIENCE
Education: Did you
graduate?
High
School ___________________________________ Yes No
College ___________________________________ Yes No
Technical Training ________________________________________ Yes No
Languages spoken in addition to
English: ____________________________________________
Can
you perform all of the job-related functions of the position(s) for which you
are applying?
Yes No If no, please explain:
_______________________________________________
Do you have current CPR certification?
Yes No Expiration Date: ___________________
Why
do you want to work for this agency?____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
PAST & PRESENT EMPLOYERS
Current
Employer:
Name: _______________________________________ Phone: _______________
Address:
_______________________________________ Position: _______________
City:
May
we contact? Yes No
Salary/Wage: __________ Supervisor: ________________
Past
Employers:
Name: _______________________________________ Phone: _______________
Address:
_______________________________________ Position: _______________
City:
May
we contact? Yes No Supervisor _____________________
Date
started: ___________ Date ended: ___________
Reason for leaving: _______________
Name: _______________________________________ Phone: _______________
Address:
_______________________________________ Position: _______________
City:
___________________
May
we contact? Yes No Supervisor _____________________
Date
started: ______________ Date ended: ___________
Reason for leaving: _______________
REFERENCES
(Give
work or medical field related references. Do not list relatives or personal
friends.)
Name: _____________________________________________ Phone: ____________________
Address: _____________________________________________ How I know: ________________
_______________________________Zip___________
Years acquainted: ____________
Name _____________________________________________ Phone ___________________
Address _____________________________________________ How I know ________________
_______________________________Zip___________
Years acquainted ___________
Name _____________________________________________ Phone ___________________
Address _____________________________________________ How I know _______________
_______________________________Zip___________
Years acquainted ___________
CRIMINAL
BACKGROUND INQUIRY
Have
you ever been convicted of a crime, other than a minor traffic offense, or pled
no contest to a crime? Yes No
If yes, please explain.
Details:
___________________________________________________________________________
(You will not be denied employment
solely because of a conviction record, unless the offense is related to the
work for which you have applied.)
EMERGENCY
CONTACT
Name: __________________________ Home phone: _____________ Work phone: ________________
Address______________________________________
Relationship to you: ________________________
“I certify
that the facts contained in this application are true and complete and to the
best of my knowledge and I understand that, if employed, falsified statements
on this application shall be grounds for dismissal. I authorize investigation
of all statements contained herein and the references listed above to give you
any and all information they may have, personal or otherwise, and release all
parties from all liability for damage that may result from furnishing same to
you.”
Signature
______________________________________ Date:
_________________________
