Careers

PERSONAL INFORMATION

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone

Are you 18 years or older*

DESIRED EMPLOYMENT

Poistion you are applying for:*

Desired Salary

Start Date*

Are you currently employed?*

May we inquire of your current employer?*

Have you ever worked for this company?*

Who referred you to Beneficial Support Services?

Friend
Employee
Advertisement
Government Placement Agency
Internet
Other

Specify

CURRENT EMPLOYER

Current Employer

Telephone

Reason for leaving

Name of last supervisor

EMPLOYMENT HISTORY

Name of Employer 1

List your last two (2) employers, assignments of volunteer activities, including experience. Explain any gap in employment in the comments section below.

Job Title

Address*

Street Address Address Line 2 City State ZIP Code

From*

To*

What was the nature of your work?*

Hourly rate

Name of supervisor

Phone

Comments

Name of Employer 2

Job Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

From*

To*

What was the nature of your work?*

Hourly rate

Name of supervisor

Phone

Comments

ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?*

(Proof of eligibility will be required before employment)

EDUCATION

High School

Name of School & Location

Number of years attended

Did you graduate?

Major

College | University

Name of School & Location

Number of years attended

Did you graduate?

Major

Professional Training

Name of School & Location

Number of years attended

Did you graduate?

Professional Certification

EMERGENCY CONTACT

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email*

Relationship

PERSONAL REFERENCES

Professional Reference 1 - Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email

Phone

Business

From

To

Professional Reference 2 - Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email

Phone

Business

From

To

Have you been convicted of a crime in the last 5 years?*

Please explain (Will not necessarily prevent your employment)

Please check the box*

I certify that the facts contained in this application are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for a subsequent discipline up to and including dismissal from employment if discovered at the later date. I understand that if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Ageless Healthcare other than the owners is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owners.

CERTIFICATION

Check all that apply*

Select All
RN
LPN
GNA/CNA
Other

State

Please list certification

SKILLS

The following information will help us place you where your skills, knowledge of nursing and preferences will be best suited

Can you do vital signs

Can you do nurses notes?

Can you do catheter care?

Can you insert catheters?

Can you start IVs?

Do you suction patients

Can you set up oxygen for patients?

Can you do neurological Assessments?

Can you give intramuscular medications?

Can you give IV medications?

Can you assess patients for admission?

Can you discharge patients?

Have you had CPR?

Do you have intensive care experience?

In which of the following areas have you had experience??

Have you had any special training in nursing? If so, what?

Preferences

Are you a licensed driver?

Will you travel 30 minutes one way?

Are you a licensed driver?

Will you work shifts at a hospital?

Will you work shifts at a nursing home?

Will you work private duty cases?

Please rate your physical condition.

Select the time of day you are available

Select your days of availability

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

How many hours a week do you wish to work?

Do you have any handicaps? If so, please describe:

If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Excellence Healthcare. This application will remain on active file for 60 days. If I am hired within this period, this form will be transferred to my individual personal file. If I am not hired or have not heard from this agency within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Excellence Healthcare.

I do hereby give the employer and/or its agents, including consumer-reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but not limited to, credit reports, criminal conviction records, motor vehicle driving records and previous employment history. Further, I hereby release from liability and hold harmless Beneficial Support Services ,it’s representative, all persons and organizations/companies for furnishing such information.

If required, I agree to a drug-testing prior and during employment or for post-accident occurrences. The employer, Excellence Healthcare is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report, which includes information as to your character, general reputation, personal characteristics and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.”

Signature*

Date

Please attach photocopies of the following.

Birth Certificate
Drivers License
Copy of Social Security card
Employment Authorization/Eligibility
CPR Certifications (if any)
Professional License (if any)
First Aid Certificate(if any)
BLS Unrestricted professional Lic (if any)
Criminal background check using CJIS

File

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