* = Required Information
Application For Employment
Personal Information
     
Date of Application:  
    (mm/dd/yyyy)
Position Applying For: *
     
Name: *
  Last First Middle
Social Security Number:  -   - 
  
Present Address: *
  Street
 
  City State Zip Code
Phone Number: * ( )  - 
Mobile Number: ( )  - 
E-mail Address: * Referred by:
If you connot be reached at above number, where may we contact you?
Name of Person:
Phone Number: ( )  - 
Required Questions
Please select either Yes or No option:
Are you legally allowed to work in this country? YesNo
Have you lived in the state of Ohio for less than 5 years? YesNo
Are you under the age of 18? YesNo
Have you ever applied to Healing Touch Home Healthcare before? YesNo
Do you have any friends or relatives that work for Healing Touch Home Healthcare?
    If Yes, name of friends and/or relatives
YesNo
Are you currently employed? YesNo
    If Yes, may we contact your current employer? YesNo
Can you travel if a job requires it? YesNo
Do you have a valid driver's license? YesNo
Do you have valid auto insurance? YesNo
Have you been convicted of a felony within the last five years? YesNo
Have you been subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions?
* A criminal record does not constitute on automatic bar to employment and will be considered only as it relates to the job in question.		 YesNo
Have you ever been convicted of any criminal violation of law, or are you now under pending investigation or charges of violation of criminal law?
    If Yes, please explain
YesNo
  (.doc and .pdf files only.)
Availability Information
Date available for work:  
    (mm/dd/yyyy)
Desired Salary Range:         
Are you available to work:   Full-Time    (Shift: 123)
Part-Time    (Shift: 123)
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Please indicate any things you will not be able to work (Be Specific):
Professional Licenses and/or Certifications
SKILL:          RN      LPN      STNA      CNA      HHA      THERAPIST      OTHER
Type Organization State Date
Issued		 Number Verif.
(Internal Use Only)
CPR Certificate Date  |    Exp. Date   |  | 
Education
Name of School Location
(City, State)		 Courses Taken Completed Type of Degree or
Certification
Received
Grammar or
Grade School		 YesNo
High School YesNo
College YesNo

Date
Vocational
or Business		 YesNo

Date
Professional
Education		 YesNo

Date
Employment Record  (List last place of employment or present position first)
Present and Former Employers Dates
Employed		 Salary Range Position & Duties
Name: 
Address: 
City/State/Zip: 
Phone:  		From:

To:

Supervisor:
 Starting:

Ending:

Supervisor:
Reason For Leaving:  
Name: 
Address: 
City/State/Zip: 
Phone:  		From:

To:

Supervisor:
 Starting:

Ending:

Supervisor:
Reason For Leaving:  
Name: 
Address: 
City/State/Zip: 
Phone:  		From:

To:

Supervisor:
 Starting:

Ending:

Supervisor:
Reason For Leaving:  
References
NAME PHONE NO. PROFESSION YRS. KNOWN
1. 
2. 
3. 
4. 
DESCRIBE ANY SPECIALIZED JOB RELATED SKILLS & QUALIFICATIONS FROM PAST EXPERIENCE:
SUMMARIZE ANY PERSONAL QUALITIES, WORK STYLE, INTERPERSONAL SKILLS WHICH WOULD ASSIST US IN PLACING YOU:
Healing Touch Home Healthcare does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment or participation in its programs, services and activities, or in employment.
 I certify that answers given herein are true & complete.
 I voluntarily give Healing Touch the right to make a thorough investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
 This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time.
 I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. i also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application.
 If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment. I will also be required to abide by all rules and regulations of Healing Touch Home Healthcare LLC.
*******************
REFERENCE CHECK FORM
Information to be completed by the Applicant
Applicant Name:    
Social Security Number:      -   - 
Present and/or Former Employers Dates
Employed		 Salary Range Position & Duties
Name: 
Address: 
City/State/Zip: 
Phone:  		From:

To:

Supervisor:
 Starting:

Ending:

Supervisor:
Reason For Leaving:  
 I hereby authorize Healing Touch Home Healthcare, LLC to obtain all and any information concerning my employment.
 I understand this is in accordance with all applicable federal & state laws.
Reference Information to be completed by the Current/Former Employer
Dates
Employed		 Salary Range Position & Duties
From:

To:
 Starting:

Ending:
  Eligible for Rehire?  YesNo
 Please choose only one for  applicant. 
  Resigned
  Temporary Employee
  Terminated
  Still Employed
 
1 - Unsatisfactory    2 - Below Average    3 - Average    4 - Above Average    5 - Outstanding
QUALITY OF WORK      1          2          3          4          5     
DEPENDABILITY      1          2          3          4          5     
COOPERATION      1          2          3          4          5     
COMMUNICATION      1          2          3          4          5     
PERSONALITY      1          2          3          4          5     
Security Code *