Revival Homecare Agency

First Name * :
Middle Name * :
Last Name * :
Street Address*
City*	State* Zip*
Home Phone Number*
May We Contact You at Work*	Work Phone Number*
Best Time to Call*
Email Address
Have you ever been employed, licensed, certified or received a degree under a different name?
Are you a citizen or otherwise legally able to work in the U.S.? (Proof of citizenship/immigration status will be required upon employment).
Are you related to any employees of Revival Homecare Agency?
If Yes, please indicate name	and relationship
Have you ever applied or worked at this organization before?
If Yes, position
Reason for leaving
How did you learn of Revival Homecare Agency? Employee Relative Friend Patient Newspaper Ad
Please indicate name of newspaper
Have you ever pled guilty to, been convicted of, or are presently charged with any violation of the law, other than a traffic or speeding violation? If Yes, please explain. (Answering Yes does not automatically disqualify you for consideration for employment). Are you currently serving probation, conditional discharge or pretrial diversion for any crime? If Yes, provide details on offense, disposition and current status

Please list all schools attended

	Name & Address	Dates	Graduate	Degree/Major
High/Prep School
College
Graduate School
Other

Please indicate all other training that may be relevant to your application

List any additional qualifications or skills you have for the position for which you have applied

List any languages in addition to English you can speak

Write

Read

Describe your computer skills

Describe office skills, business machine training and experience

If required, do you hold a valid license/certification/registration for the position for which you have applied?

If yes, please state license/certification/registration number

Expiration date

Have you ever been denied a professional or occupational license, certification or registration?
If yes, provide issuing state(s), type of license/certification/registration and numbers

Has any license, certification or registration that you hold/held ever been investigated, revoked, suspended, limited or subject to discipline by any board or governing authority?

If yes, provide issuing state(s), type of license/certification/registration and numbers and please explain in detail

Have you ever been denied professional liability insurance or had such a policy cancelled?
Have you ever been named as a defendant in a professional liability claim?
If yes to either question, please explain in detail

Do you hold a valid driver's license?

Do you have an automobile insurance policy in effect?
(A certificate of insurance naming Revival Homecare Agency as a certificate holder is required at the time of employment)

Please provide employment information for the prior ten years or your four prior employers, whichever is greater. Explain all periods of unemployment. Please begin with your current or most recent employer. References will be required before employment.
Employer (Current or most recent employer)
May we contact?
Street Address
Phone Number
City	State Zip
Salary
Worked There From	To
Position Held	Supervisor
Reason For Leaving


Employer
May we contact?
Street Address
Phone Number
City	State Zip
Salary
Worked There From	To
Position Held	Supervisor
Reason For Leaving


Employer
May we contact?
Street Address
Phone Number
City	State Zip
Salary
Worked There From	To
Position Held	Supervisor
Reason For Leaving


Employer
May we contact?
Street Address
Phone Number
City	State Zip
Salary
Worked There From	To
Position Held	Supervisor
Reason For Leaving


Employer
May we contact?
Street Address
Phone Number
City	State Zip
Salary
Worked There From	To
Position Held	Supervisor
Reason For Leaving


Employer
May we contact?
Street Address
Phone Number
City	State Zip
Salary
Worked There From	To
Position Held	Supervisor
Reason For Leaving

Please list the names of three individuals whom you have known for at least two years. No employers or relatives.
Name
Years Known
Street Address
Phone Number
City	State Zip
Relationship (Friend, Pastor, Teacher, etc.)


Name
Years Known
Street Address
Phone Number
City	State Zip
Relationship (Friend, Pastor, Teacher, etc.)


Name
Years Known
Street Address
Phone Number
City	State Zip
Relationship (Friend, Pastor, Teacher, etc.)

Please Read Carefully

I verify that all the information which I have provided on this application and in any resumes and exhibits are true, correct and complete. I understand that any false, misleading, incomplete or omitted information will result in rejection of my application or dismissal from employment, whenever discovered. If my application is considered for employment, I authorize Revival Homecare Agency to conduct an investigation of my suitability for employment and to obtain verification of information that I provided on this application, resumes and exhibits. I authorize such information to be used for any decisions related to my hiring and continued employment. Revival Homecare Agency will conduct a background and reference check on candidates offered positions of employment.

I understand that this application is not a job offer. If hired, I understand that the first one hundred twenty (120) days of employment at Revival Homecare Agency will be considered as a period of adaptation and employment may be terminated during this period by either the employee and/or the employer with no eligibility for benefits or termination pay. My employment is not for a stated period of time and I may resign or be terminated with or without cause at any time, at the option of either myself or Revival Homecare Agency. I understand that I may be working in one or all subsidiaries of Revival Homecare Agency Care and that my shift or schedule may vary.

Employment is subject to completion of pre-employment procedures, including but not limited to, verifying employment and personal references, as appropriate criminal background check and driving record, and verification of licensure, certification or registration. In addition, if hired, applicants must complete a Federal I-9 form and provide verifiable documentation of their legal right to reside and work in the United States. I also understand that offer of employment is contingent upon passing a pre-placement physical exam and health screening and may require a drug testing.

If employed, I will comply with all policies, procedures and work rules. In the event that I am photographed or interviewed during the course of my employment, Revival Homecare Agency has my permission to use any and all materials gathered.

Please indicate your acceptance of the terms of this application

(Attach your CV)