Employment Application

FirstCare Home Health
3901 Normal Blvd - Ste 102
Lincoln, NE 68506
402-435-1122
Application for Employment


Position(s) Applying For: (please check all that apply)

Certified HHA/CNA(75hr)
LPN
RN
Physical Therapist
OT/ST
Home Care
Part-Time
Full-Time
Other/Specify
 
Clinical Applicants
 
License Type Date of Expiration State Number
 
Last Name:       First Name:       Middle:
 
Address:       City:       State:       Zip:
 
Phone Number(s):     
 
List best times to call:
 
Have you ever filed an application here before? Yes   No     If yes, give date  
Have you ever been employed by FirstCare before? Yes   No     If yes, give date  
Are you able to perform the tasks this job requires? Yes   No     If no, please explain  
Are you eligible for employment in this country? Yes   No                               
Have you ever had a criminal conviction? Yes   No     If yes, please explain  
Are you on a lay-off and subject to recall? Yes   No                               
Will you travel if job requires it? Yes   No                               
Can you meet the attendance requirements? Yes   No                               
Are you willing to work overtime? Yes   No                               
Have you ever been bonded? Yes   No                               
Are you CPR Certified? Yes   No     If yes, where and when  
Do you speak any foreign languages? Yes   No     If yes, please specify  
Do you have a reliable automobile? Yes   No                               
Do you have automobile insurance? Yes   No     If yes, give date  
 
Employment History
 
Please list your last four(4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments below.
 
Employer   Telephone   Begin date End Date
Address   Starting Hourly Rate/Salary   Final Hourly Rate/Salary
Immediate Supervisor and Title   Job Title
Summarize the nature of the work performed and job responsibility
Reason(s) for Leaving
May we contact for a reference?    Yes  No
 
 
Employer   Telephone   Begin date End Date
Address   Starting Hourly Rate/Salary   Final Hourly Rate/Salary
Immediate Supervisor and Title   Job Title
Summarize the nature of the work performed and job responsibility
Reason(s) for Leaving
May we contact for a reference?    Yes  No
 
 
Employer   Telephone   Begin date End Date
Address   Starting Hourly Rate/Salary   Final Hourly Rate/Salary
Immediate Supervisor and Title   Job Title
Summarize the nature of the work performed and job responsibility
Reason(s) for Leaving
May we contact for a reference?    Yes  No
 
 
Employer   Telephone   Begin date End Date
Address   Starting Hourly Rate/Salary   Final Hourly Rate/Salary
Immediate Supervisor and Title   Job Title
Summarize the nature of the work performed and job responsibility
Reason(s) for Leaving
May we contact for a reference?    Yes  No
 
Educational Background
 
List the three (3) schools attended, starting with the last one first. List the number of years completed.
Indicate degree or diploma earned, if any. List your Grade Point Average or Class Rank.
Finally list your Major and Minor fields of study (if applicable).
 
School # of Years Degree/Diploma GPA/Class Rank Major/Minor
 
References
List name and telephone number of three (3) business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
 
Name Telephone Number Years Known  
 
 
 
 
 
List professional, trade, business or civic associations and any offices.
(Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status)
 
Organization Offices Held
 
 
List special accomplishments, publications, awards.
(Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status)
 
 
List any additional comments or information you would like us to consider, including special skills and qualifications acquired from employment or other experiences that may qualify you to work with our company.
 
 
How did you hear about FirstCare?
 
Days and Hours available for assignments:
Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday
 
Are you fluent in sign language?   Yes  No
 
Are you fluent in any foreign language?   Yes  No     If Yes, please list:
 

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed.

I give the Employer the right to investigate all references and to secure the additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The Employer is an Equal Opportunity Employer, the Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.

This application is current for only sixty (60) days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

By clicking Send Application, you acknowledge everything is correct.