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info@ameristarhh.com
(614) 489-7272
5668 Columbus Square, Columbus, OH 43231
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Home
About
Services
Personal Care
Medical Home Health
Private Duty
Passport & DODD programs
Homemakers & Senior Companions
Advanced Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Therapy
Home Health Aides
Blog
Service Areas
Careers
Forms
Contact
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HHA & STNA Application for Employment
All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.
Personal Information
Last Name
First Name
Middle Name
Date
MM slash DD slash YYYY
Street Address
Home Phone
City, State, Zip Code
Business Phone
Emergency contact (person not living with you)
Have you ever applied for employment with this Agency?
Yes
No
How many hours a week are you available for work?
Are you legally eligible for employment in the United States?
Yes
No
How did you learn of our organization?
Online Ad
Agency employee
Other
Are you willing to work
Evenings?
Weekends?
Position applying for
Education
College
School Name
Location of School
Course of Study
Degree/Dip
Vo-Tech or Trade
School Name
Location of School
Course of Study
Degree/Dip
High School
School Name
Location of School
Course of Study
Degree/Dip
Other
School Name
Location of School
Course of Study
Degree/Dip
Employment
List the last five years employment history, starting with the most recent employer.
1. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
2. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
3. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
4. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
5. Company Name
Telephone
Address
City, State, Zip Code
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Starting Pay
Job Title and describe your work
Reason for leaving
Was your last name different from your present name during the above listed jobs?
Yes
No
If yes, what was your name?
Are you currently employed?
Yes
No
Do you have reliable transportation?
Yes
No
Professional References
Persons who can furnish information about job performance
1. Name
Telephone
Address
2. Name
Telephone
Address
3. Name
Telephone
Address
General
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?
Yes
No
Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full
Are you capable of performing the job set forth in the job description?
Yes
No
If you answered No, which job requirement can you not meet?
Credentials/specialized skills & qualifications/equipment operated
List all states in which licensed giving registration and expiration date. Summarize special jobrelated skills and qualification acquired from employment or other experience.
Please read all statements below before signing this application
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL
I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.
This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.
I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.
Date
MM slash DD slash YYYY
Signature
(1) Applicant Reference Check
To Whom It May Concern:
The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
To be filled out by applicant:
Applicant Name
Date of Application:
MM slash DD slash YYYY
Previous Employer
Contact Person
Address
Phone
I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
Applicant’s Signature
Date
MM slash DD slash YYYY
To be completed by previous employer:
Date of employment:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position Held
Would you rehire this individual?
Yes
No
Responsibilities
Reason for Leaving
Rate of Pay: (weekly/biweekly/salary)
Additional comments (training/skills)
Reference check performed by
(2) Applicant Reference Check
To Whom It May Concern:
The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
To be filled out by applicant:
Applicant Name
Date of Application:
MM slash DD slash YYYY
Previous Employer
Contact Person
Address
Phone
I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
Applicant’s Signature
Date
MM slash DD slash YYYY
To be completed by previous employer:
Date of employment:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position Held
Would you rehire this individual?
Yes
No
Responsibilities
Reason for Leaving
Rate of Pay: (weekly/biweekly/salary)
Additional comments (training/skills)
Reference check performed by
Email
This field is for validation purposes and should be left unchanged.
Let's Talk
Name
Phone
Email
Message
Comments
This field is for validation purposes and should be left unchanged.
Schedule Consultation
Name
Phone
Email
Best Time to Call
Morning
Afternoon
Evening
Message
Email
This field is for validation purposes and should be left unchanged.
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