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Employment Application
Angel Homecare is an Equal Opportunity Employer and is committed to our policy of ensuring equal opportunity for all employees and qualified applicants without regard to race, color, religious creed, national origin, sex, age, handicap or status as a disabled or Vietnam-era veteran. In accordance with Massachusetts G.L. c. 149 and 19B, it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
Position:
  
Years of Experience
    
First Name:
Last Name:
MI:
Street:
City:
State:
Zip:
Phone:
Cell:
Fax:
E-Mail:
 
 Have you ever been convicted of a felony?
Yes No
 Have your credentials ever been under investigation?
Yes No
 If either above questions is answered "Yes" please supply details describing the incident.
 
Professional Certification/Licensure
   Nurse's License:
  
State: 
Expiration Date:
   CNA License:
  
State:
Expiration Date:
 Certifications: Please check all that apply
IV
BLS
CPR
   
 Professional Experience: Please check areas of clinical expertise that you are applying for
Acute Care
Long Term Care
Pediatrics
Home Health
Hospital
 
M.D.  Office
Rehabilitation
Skilled nursing
Hospice
   
List any pertinent skills other than work experience that we should consider.
Where would you like to work?
  Enter Hours that best apply:
A - First Shift
B - Second Shift
C - Third Shift
D - Weekends
Full-Time    Part-Time    All
Monday
A
B C D
Tuesday A B C D
Wednesday A
B
C
D
Thursday A B C D
Friday A B C D
Saturday A B C D
Sunday A B C D
Date available to start:
Prior employment
Employer 1 (Current/most recent)
Employer Name:
Phone Number:
Street Address:
City:
State:
Zip Code:
Date Started:
Ending Date:
Supervisor:
Title:
Description of Duties/Responsibilities:
Reasons for Leaving this job:
How did you here about Angel Homecare?
May we contact your previous employer?
Yes No
   
 
Employer 2 (Current/most recent)
Employer Name:
Phone Number:
Street Address:
City:
State:
Zip Code:
Date Started:
Ending Date:
Supervisor:
Title:
Description of Duties/Responsibilities:
Reasons for Leaving this job:
May we contact your previous employer?
Yes No

 
I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its President, and then only when in writing and signed by the President, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing.
Date:
Signature:
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Angel Homecare Employment Application Form - 10/28/02