Apply for Job Application

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Job Application
ID:HL-101
Location:General Application ( No Set Location)
Disciple :Client Services
Salary Range:N/A
Time of Shift:AM, Mid-Day, PM
Job Status:Full Time
Days:Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday
Hours:NA
Resume
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Application for Employment
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

Yes   No

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

Reference 2

Reference 3
Licenses and Certifications
* Do you hold any professional licenses of certifications?
Yes   No
Please list all the professional licenses and certifications you hold::
* Have you ever had any actions taken against you or had any warnings, disciplinary actions, or other limitations placed upon your license, by any state board?
Yes   No
* Have you ever been, or are you currently excluded, debarred, or suspended from participation in any Federal or State healthcare programs or in Federal procurement or non-procurement programs?
Yes   No
Please use the space below for additional information in correlation with any of the above three questions:
* Please select all of the skills with which you have had experience working:
Bi-Pap / C-Pap
Care & Management
Central Line
G-Tube
Catheterization
TPN
Tracheostomy
Ventilator
IV Therapy
Location Applying For

Please state the location you are applying for: (City, Zip Code)

COVID-19 Screening
* Have you traveled outside of the United States in the last 14 days?
Yes   No
If Yes, please state the location:
* Have you had contact with anyone who has tested positive for COVID-19 in the last 14 days?
Yes   No
* Have you experienced any of the following symptoms in the last 14 days?
* Fever greater than 100.4
* Cough
* Shortness of breath or difficulty breathing
* Consistent fatigue
* Muscle or body aches
* New loss of taste or smell
* Congestion or runny nose
* Diarrhea
Yes   No
* Are you currently experiencing a temperature over 100 degrees Fahrenheit, difficulty breathing or coughing?
Yes   No

If you have answered Yes to any of the first two questions , please contact your primary care provider or your State Department of Health for further directions.
         California Department of Health - COVID-19 Information Line:
         1-833-4CA4ALL (1-833-422-4255)
If you have answered No to the first two questions but  Yes to any of the remaining questions, please contact your healthcare provider.



Please DO NOT visit a medical facility unless your symptoms are severe or if you are severely ill. Meanwhile, do not get close to anyone with a compromised immune system or other underlying health conditions.

* Have you received both doses of your COVID-19 Vaccine?
Yes
No
If you have received two doses of your COVID-19 Vaccine, have you also received your booster shot?
Yes
No
Authorization
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.


I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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