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Employment Application
BEFORE YOU APPLY -- PLEASE READ THE FOLLOWING:
RN openings for both PRN and Full-Time
Home Service Worker positions are
PRN
-
Full-time hours are NOT guaranteed.
After 1,000 hours in the field with positive evaluations for reliability and timeliness, HSW are granted full-time status.
All HSW must have: Clean driving record, valid license and auto insurance. Ability to pass background and drug screen.
HSW must have reliable transportation to and from shifts.
HSW must be at least 18 years of age and have a high school diploma or equivalent.
Please continue with application if you feel you can meet this criteria.
*
Todays date
Year
/
Month
/
Day
First Name
Last Name
Address
City
State
Zip
Email
Phone Number
Employment Eligibility Questions
Do you Have a Current Drivers License?
- Please Select -*
Yes
No
Do You Have Current Auto Insurance?
- Please Select -*
Yes
No
Are You a US Citizen?
- Please Select -*
Yes
No
If No, Are you Authorized to Work in the US?
- Please Select -*
Yes
No
Availability Questions
Are You Currently Employed?
Please Select*
Yes
No
If Yes, What Date Are You Available?
Year
/
Month
/
Day
I am looking for:
Please Select
Part-Time
Full-Time
*
I am seeking to work as/in
HSW Peoria area
HSW Fulton area
HSW Knox area
HSW Galesburg area
RN-LPN
I am willing to travel (select all that apply)
5-10 M
10-25 M
25 M+
*
Are you a CNA
Yes
No
Shift Preference and Available Hours
Home Service Worker Positions are PRN and based on case need. Please
BE SPECIFIC
in the shifts, days and hours you are realistically available each day.
It is a requirement of Home Health to be available every other weekend. Please be aware of this requirement before submitting your application.
Specific hours you are available each day.
*
What shift preference do you have?
1st
2nd
3rd
Open
*
What days are you available each week?
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
Education
HighSchool
Graduated On
Type of Diploma
College
Year Graduated
Type of Degree
Skills
References
Reference Name
Phone #
Relationship
Reference Name
Phone #
Email
Relationship
Reference Name
Phone #
Email
Relationship
Previous Employment
Previous Employer 1
Supervisor
Phone #
*
From
Year
/
Month
/
Day
*
To
Year
/
Month
/
Day
Duties Performed
Previous Employer 1
Phone #
*
From
Year
/
Month
/
Day
*
To
Year
/
Month
/
Day
Duties Performed
Military Service
Branch Served
From
Year
/
Month
/
Day
To
Year
/
Month
/
Day
Submit