Employment Application - Stay Well Home Health

Step 1 of 6 - Personal Information

Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
How long have you lived at this address?
Telephone No.*
Social Security No.
Previous Address*
Street Address Address Line 2 City State ZIP Code
How long did you lived at previous address?
How did you hear about our company?*
- Craigslist
- Indeed
- Current Employee
Current Employee*
Have you ever worked here before?*
- Yes
- No
If so, when and in what position(s)?*
Position(s) applying for:*
Rate of pay desired:*
Available to work:*
- Full-time
- Part-time
Are you currently employed?*
- Yes
- No
Are you 18 years of age or older?*
- Yes
- No
Date available to start work?*
MM slash DD slash YYYY

Personal References

(Give the names of three persons not related to you whom you have known for at least one year)

Name	Address	Occupation	Phone	Years Known
					Edit Delete
There are no Personal References.

Maximum number of personal references reached.

Applicant Statement
I certify that all the information set forth during my employment application process is true and complete. I understand and agree that any falsification, misrepresentation or omission either on the employment application form or in my responses to questions asked during the interviewing or examination process may disqualify me from further consideration for employment, or if employed by the Company, will subject me to immediate termination, whenever the falsification or omission is discovered. In this regard, where an item is left blank on the employment application, it is because there is no information within its scope. My signature authorizes the Company or its authorized agents to conduct a thorough investigation of all statements, written and oral, made by me during the employment application process, including without limitation, information concerning my employment positions, law enforcement record and educational background. I hereby authorized all persons, companies, or other entities connected with any such informational request, including without limitation, current or prior employers and law enforcement agencies to provide any and all information they may have regarding me or my employment. I release and agree to indemnify the Company, its authorized agents and its employees and all other persons, companies, and other entities from any and all liability arising out of such investigation, including without limitation, any liability for furnishing information or for taking any action based on the information provided. I authorize and consent to the submission of my fingerprints and a request for a criminal records check to comply with Ohio Senate Bill 160. I understand that if I am made a contingent offer of employment and the results of the criminal records check indicate I have been convicted (this includes, without limitation, pleading guilty, pleading no contest or having a finding of guilt) of one or more of the crimes listed on the previous page and the company determines I do not meet the personal character standards developed by the Ohio Department of Health, I will be subject to immediate termination. I further understand that if the Company does not receive the criminal records check back within 60 days my employment will also be terminated. I may be eligible for rehire upon receipt and review of the results of the criminal records check. I understand that a drug and/or alcohol screen may be required before and during my employment. In addition, I authorize a medical examination, including a drug and/or alcohol screen, by an examiner selected by the Company if I am made a contingent offer of employment. I release and agree to indemnify the Company, its authorized agents and its employees and all other persons, companies and other entities from any and all liability arising out of any medical examination or drug/alcohol screen or for the taking of any action based on the results of any medical examination or drug/alcohol screen. I certify that I am a citizen of the United States and, if not, I can provide required documentation permitting me to work in the United States. I understand and agree that if I am employed, my employment is at-will so that I may terminate my employment at any time and for any or no reason. Likewise, the Company may terminate my employment at any time and for any or no reason. I also understand and agree that nothing contained in the employment application or in the granting or conducting of any interview or anything set forth in any oral or written statement, communication, or policy now or in the future constitutes or creates or is intended to constitute or to create a contract or promise between me and the Company for employment, hours of work, or for the providing of benefits. Moreover, I acknowledge that the Company reserves the right to modify, revoke, suspend, terminate or change any or all of its plans, policies, or procedures at any time, without prior notice. No promises or guarantees regarding employment, hours of work, or for the providing of benefits have been made to me and I understand and agree that no such promise or guarantee is binding on the Company unless they are expressed promises, made in writing, and signed by the Administrator of the Company.
Signature*
CAPTCHA
Hidden
Applied Date
MM slash DD slash YYYY

Type of School	Name	Course of Study	Did you graduate?	List Degree or Diploma
					Edit Delete
There are no Educational Backgrounds.

Employer Name	Employer Address	Employer Telephone No.	Job Duties	Reason for Leaving	Employment Start Date	Employment End Date	Ending Salary	Supervisor's Name	Name Worked Under
										Edit Delete
There are no Work Experiences.

License/Certification	State of Issuance	Licensing Agency	Expiration Date	Number	If issuing state is not Ohio, have you applied for reciprocity?
						Edit Delete
There are no License and/or Certifications.

Step 1 of 6 - Personal Information

Applicant Statement