Application for Employment

Altamaha Homecare, Inc. is an equal employment opportunity employer dedicated to a policy of nondiscrimination in employment upon any basis including race, color, religion, sex, age, national origin, or disability.

Employment with AHC is at will, so either party may terminate the relationship at any time and for any reason.

Altamaha Homecare, Inc. is a DRUG FREE WORKPLACE. All applicants will be tested after receiving an offer of employment. Any applicant who refuses to take a drug test will not be considered for employment. Any applicant who fails the drug test by having a confirmed positive result will not be considered for employment.

Due to the nature of certain jobs, applicants may be subject to a criminal background check.

This application will be valid for six months from the date completed.

* - Required Fields
Employment Application	* Date

Position applied for

Type of work desired

Full time Part Time Temporary

Date available to start

PERSONAL DATA

Full Name

Social Security Number

Current Address (include City, State and Zip Code information)

Permanent Address (leave blank if the same as your current address)

Daytime Phone

Evening Phone

In case of emergency, please notify

GENERAL INFORMATION

Have you ever applied for a job with this company in the past? If yes, please give the date of application and the position you applied for. State your name at the time, if different from present name. *


Details

Have you ever been employed by this company in the past? If yes, please give dates of employment, position held, and state your name while employed, if different from present name. *


Details

If hired, will you be able to work during the normal days and hours required for the positon(s) for which you are applying? If no, please explain. (Regular working hours are Monday-Friday, 8AM - 4:30PM with a 30 minute lunch break. There may be weekend on call hours.)


Details

Are you capable of satisfactorily performing the essential function of the job(s) for which you are applying? If no, please explain.


Details

Have you ever been suspected, charged or convicted of an offense, misdemeanor/crime, or released from prision in the past 10 years? NOTE: A yes answer does not automatically disqualify you from employment since the nature of the offense, date, and type of job for which you are applying will be considered. If yes, please explain. *


Details

Have you ever abused, neglected, sexually assaulted, exploited, or deprived any person? Have you subjected any person to serious injury as a result of intentional or grossly negligent misconduct?

Do you have a valid driver's license, auto insurance and your own transportation? NOTE: Having a driver's license and insurance is essential to this job because you are required to make home visits to patients' homes, unless you are applying for a clerical position)

Do you have all the necessary licenses and professional certification(s) listed in the job announcement, job advertisement, or job description to perform the job(s) for which you are applying? If no, please explain.


Details

SCHOOLS ATTENDED

NAME OF SCHOOL AND LOCATION

DID YOU GRADUATE?

DEGREE, DIPLOMA OR CERTIFICATION

GRADE POINT AVERAGE

MAJOR COURSE OF STUDY

High School

Highest Grade Completed

DO NOT ANSWER

Technical or vocational business or military training

College or University

Graduate School

Professional Seminars

References: List three individuals who are not former employers or relatives

Name

Address

Phone

Occupation

Name

Address

Phone

Occupation

Name

Address

Phone

Occupation

Employment History - Present and former employers

May we contact your present employer? YES NO

Company Name
Address, including City, State & Zip Code
Job Title
Job Duties
Pay Rate
Dates of Employment	From:
	To:
Supervisor
Supervisor Phone
Reason for Leaving
Your name if different while employed

Company Name
Address, including City, State & Zip Code
Job Title
Job Duties
Pay Rate
Dates of Employment	From:
	To:
Supervisor
Supervisor Phone
Reason for Leaving
Your name if different while employed

Company Name
Address, including City, State & Zip Code
Job Title
Job Duties
Pay Rate
Dates of Employment	From:
	To:
Supervisor
Supervisor Phone
Reason for Leaving
Your name if different while employed

Please read carefully before signing. NOTE: TYPING YOUR NAME AND SUBMITTING THIS DATA IS YOUR ACKNOWLEDGEMENT AND ACCEPTANCE OF THE STATEMENT BELOW:

I promise that the information provided in this employment application and accompanying resume (if any) is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment, if discovered at a later date. I agree to immediately notify the company if I should be convicted of a crime while my application is pending, or during my period of employment, if hired.

I authorize the investigation of all statements contained in this application (and accompanying resume, if any). I also authorize the company to contact my present employer (unless otherwise noted in this application form), past employers, and listed references. I understand that the company may request an investigative consumer-reporting agency that includes information as to my character, general reputation, personal characteristics, and mode of living. I understand that the investigative consumer report may involve personal interviews with my neighbors, friends, relatives, former employers, schools and others. I also understand that under the Fair Credit Reporting Act I have the right to make a written request to the company within a reasonable time, for the disclosure of the name and address of the consumer reporting agency, so that I may obtain a complete disclosure of the nature and scope of the investigation.

Date

Signed

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