Apply - Care Placement Home Health Agency

Recruiting Form

Thank you for your interest in contracting with our agency. We look forward to reviewing your experience and skills. Please submit the following information in order to be considered for a contract caregiver position.

1 Applicant Information

2 Education, Certifications & Credentials

3 Work History

Work History
Please provide your most recent positions.
Employer*
Supervisor*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Date Employed*
MM
DD
YYYY
To
Leave blank if you are still in this position.
MM
DD
YYYY
Reason for Leaving*
Employer
Supervisor
Phone
Address
Street Address Address Line 2 City State ZIP Code
Date Employed
MM
DD
YYYY
To
MM
DD
YYYY
Reason for Leaving
Employer
Supervisor
Phone
Address
Street Address Address Line 2 City State ZIP Code
Date Employed
MM
DD
YYYY
To
MM
DD
YYYY
Reason for Leaving
Additional Information
Professional References
Please provide the name and phone number of at least two professional references.
Professional Reference 1
Professional Reference 2
Professional Reference 3
Why did you become a CNA/HHA?
APPLICATION AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION*
This release and authorization acknowledges that this company may now or at any time while you are under contract, conduct a verification of your education, previous employment/work history, contact personal references, require that you provide a urine specimen or blood specimen to be tested for the presence of drugs or alcohol and receive any criminal history record information pertaining to you that may be in the files of any federal, state, county, or local criminal justice agency and/or other information as deemed necessary to fulfill job requirements. The results of this verification process will be used to determine eligibility under this company's placement policies. I authorize Care Placement Home Health Agency, Inc. and any of its agents/designated company personnel, to disclose orally and in writing the results of the verification process. The information obtained will not be provided to any other parties other than to the designated authorized representatives of this company. All results will be kept CONFIDENTIAL. I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of placement is true and complete to the best of my knowledge. I understand that if I am placed, any false statement will be considered as cause for possible dismissal.
- I agree
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Recruiting Form

Please select your skills and preferences.

Education & Training

Certifications and Credentials

Work History

Professional References