© 2018 by Home Care Advantage. 

3857 Birch St. #411 Newport Beach, CA 92660

Tel: 213-251-8880

Fax: 213-251-8885

Application for Employment

Application for Employment

Date

Personal Information

D.O.B

Last Name

First Name

Middle Initial

Current Address

Home Phone

Cell Phone

Email

Height*

Weight*

Ethnicity*

* Information is collected for matching nurse-to-patient criteria but it is not required for employment.

Do you have a legal right to work and be employed in US?

Have you ever worked for this company before?

If yes, when?

Have you ever convicted of Felony?

If yes, explain

Have you ever filed for worker's comp before?

If yes, when?

Explain

Person to notify in case of emergency

Education

High School

Address

From

To

Did you graduate?

Degree

College

Address

From

To

Did you graduate?

Degree

Other

Address

From

To

Did you graduate?

Degree

Classification

Base on your education and experience in nursing, type one or more: ICU/CCU, E.R., D.O.U, MED/SURG, PEDS, L&D, NICE, O.R., Recovery, Psych, ISU, Oncology, Geriatric, Post Partum, etc. 

Experience

Professional Data

License Type

Number

Expiration Date

First Aid Expiration Date

C.P.R. Expiration Date

ADVANCED EDUCATION/OTHER TRAINING: (Include workshops, in-service ad other seminars attended). Please provide us certificate copies if available.

Upload File
Max File Size 15MB

COURSE/TRAINING

INCLUSIVE DATE

Do you drive?

Do you have a car available for work?

Do you smoke?

Date available to work?

What foreign languages other than English can you speak and understand?

Employment History

(List below five employers starting with the most recent one)

Date/Month/Year

Position

Date/Month/Year

Position

Date/Month/Year

Position

Date/Month/Year

Position

Date/Month/Year

Position

Name, Address, and Phone Number

Reason for leaving

Name, Address, and Phone Number

Reason for leaving

Name, Address, and Phone Number

Reason for leaving

Name, Address, and Phone Number

Reason for leaving

Name, Address, and Phone Number

Reason for leaving

I authorize investigation off all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal.

Date:

Name/Signature: