1378A Corporate Center Pkwy EMPLOYMENT APPLICATION

Santa Rosa, CA 95407 Equal Opportunity Employer

707-546-8773
FAX 707-546-8788
[email protected] Date: ___________________

NAME (Last) (First) (Middle) Home Phone No.

ADDRESS (No. & Street) (Apt.#) (City) (State) (Zip) Cell Phone No.

Legally Shifts Desired (Circle) Schedule: (Circle) Email

Authorized Day Afternoons Full Time
to Work In Nights 12 Hrs Part Time
the U.S.?
Position Desired or Area of Interest

Person to Notify in case of Emergency Relationship Home Phone No.

Address Cell Phone No.

Who referred you to this company? Online Advertising Employee_________________ Other____________

Are you legally eligible for employment in the United States? Yes No

Have you worked for the employer previously? Yes No

Do you have reliable transportation if hired? Yes No

Are you registered or certified by any professional organization, or do you hold a professional or occupational license in
the State of California? Yes No If yes, please specify: _________________________________________

Registration or License No. _______________________ Expiration Date _______________ Type ___________________

Language ability – List those you could use in the position applied for:
Language_________________________ Speak Read Write

Language_________________________ Speak Read Write

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 Education
Course or Major Degree/Certification
Type of School Name of School Location
Subjects
High School

College/University

School of Nursing

Graduate School

CNA Program

Other
__________________

LIST OF PREVIOUS EMPLOYERS – MOST RECENT FIRST!

NOTE: PLEASE GIVE ACCURATE, COMPLETE INFORMATION ON ALL FULL OR PART TIME POSITIONS HELD.

Dates Month-Year Employer Responsibilities

From Name Title of Position

To Address Duties

Final Salary Phone Number

Supervisor’s Name Type of Business

Reason for Leaving

May we contact your present employer ______

Dates Month-Year Employer Responsibilities

From Name Title of Position

To Address Duties

Final Salary Phone Number

Supervisor’s Name Type of Business

Reason for Leaving

May we contact your present employer ______

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Dates Month-Year Employer Responsibilities
From Name Title of Position

To Address Duties

Final Salary Phone Number

Supervisor’s Name Type of Business

Reason for Leaving

May we contact your present employer ______

Dates Month-Year Employer Responsibilities

From Name Title of Position

To Address Duties

Final Salary Phone Number

Supervisor’s Name Type of Business

Reason for Leaving

May we contact your present employer ______

Do you have special certifications in any area? (i.e. ACLS, PALS, etc.) Yes No
If yes, please list type and expiration date:________________________________________________________________

__________________________________________________________________________________________________

Please check the following for which you have recent experience:
HOME CARE:

_____ Hourly _____ Visits/Bath Visits _____ Mom/Baby Visits _____ Private Duty Shifts

_____ Live In’s _____AIDS/HIV _____ Dementia _____Develop. Disabled

_____ Geriatric _____ Hospice _____ Other: (Specify) _______________________________

FACILITY STAFFING:

_____Clinics _____OR _____Dr’s Office _____ Ortho _____ ER

_____PACU _____Hospice/Palliative Care _____ Peds _____ ICU/CCU _____Tele

_____PICU _____Labor & Delivery _____ Postpartum _____Psych _____Sitter

_____ Med/Surge _____Rehab: _____Acute _____Subacute _____Nuero

_____NICU _____SNF’s _____Nursery _____TCC’s _____Oncology

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I have been provided with a job description for the position for which I am applying Yes No

After considering this job description, do you have the ability to perform this job for which you have applied, with or
without reasonable accommodation?

Yes No If not, please explain: ______________________________________________________________________

__________________________________________________________________________________________________

NOTICE OF MEDICAL EXAMINATION

Any offer of employment may be contingent upon your ability to pass a medical examination prior to the
commencement of employment, to establish your ability to perform the functions of your job.

MILITARY
If you served in the military, please list any relevant skills that you acquired during your service: ____________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

DEPARTMENT OF SOCIAL SERVICES HOME CARE AIDE STATE REGISTRY

(This is not a requirement to work for our agencies)
Are you registered with the State of California as a Home Care Aide? Yes No

If yes, what is your Home Care Aide Personnel ID (PER ID / HCA ID): ___________________________________________

APPLICANTS CERTIFICATION AND AGREEMENT

(Please read carefully)
1. Certification of Truthfulness. I certify that all statements on this Application for Employment are true to the best of my knowledge. I
understand and agree that the statements made herein may be investigated and if found to be false with be sufficient reason for not being
employed, or if employed, will be cause for dismissal when discovered. Any omissions can and will be grounds for termination.

2. References. I authorize the references I have listed above, and any prior or current employer of mine to give you any and all information
concerning my previous employment, including disciplinary information, and any pertinent information they may have, personal or otherwise, and
in exchange for my consideration of employment. I release all parties from all liability for any damage that may result for furnishing information to
you. Also, I hereby waive written notice to me that employment information is being provided by any person or organization.

3. I certify that I realize I will be conditionally hired pending passing a background check, health assessment, and/or drug testing.

4. Employment At-Will. If hired, in consideration of my employment, I agree to abide by rules, policies, and procedure of the Company. I
further agree that my employment with the Company is at-will and can be terminated for any reason, with or without cause, and with or without
notice at any time. I understand that the Company may, from time to time, make unilateral changes in its rules, regulations and personnel practices
and policies which will affect me and that my employment may be subject to unilateral adjustments in compensation, fringe benefits and other
terms and conditions of employment, including layoffs. I also understand that no agent or representative of the Company has any authority to
many any agreement contrary to the foregoing, except by a written employment contract signed by me and the President of the Company or
designate.

Signature: _________________________________________________________________ Date: __________________________

Printed Name: ______________________________________________________________

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