(516) 931-5850

EMPLOYER’S STATEMENT

All information on this application is confidential. The Agency will not contact your present employer without your consent. In accordance with federal, state, and local laws, Agency does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, age, disability, or any other legally protected status. Applicants may request any reasonable accommodation to participate in the application process.

Applicant Information

* Gender:MaleFemale
* Marital Status Select:MarriedSingle
* Date of Birth
* Employment Type:PCAHHA
* Application Date:

Applicant Address:

Additional Information

Do you have experience working with computer?YESNO
Do you have a Valid Driver’s License?YESNO
Graduated?YesNo

Professional Licenses and/or Certificates

Course Type: PCA
Date Successfully Completed:
Course Type: HHA
Date Successfully Completed:

Employment History

* Please begin with your most recent employment and proceed back to at least 10 years of Employment History

Date of Employment: From: To:
PositionPCAHHA
Date of Employment: From: To:
PositionPCAHHA

Additional References

Emergency Contact Information

1st

*Please begin with your most recent employment and proceed back to at least 10 years of Employment History

* Relationship:

MotherFatherSisterBrotherCousinHusbandWifeSonDaughterFriendOther

2nd

* Relationship:

MotherFatherSisterBrotherCousinHusbandWifeSonDaughterFriendOther

Notification Preferences

Mobile/Text MessageVoice messageEmail
Have you ever been employed with us before?
YesNo
Have you ever been convicted of healthcare fraud?
YesNo
Have you ever been convicted of a crime?
YesNo
Have you ever been assessed and paid any civil monetary penalties in connection with offenses related to the provision of health care?
YesNo
listed by a Federal agency as excluded, debarred or otherwise ineligible to participate in federally funded health care programs?
YesNo

Applicant's Statement

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize the investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of 60 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “At Will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I understand that at no time am I to render services beyond a normal assigned tour of duty without express authorization from the Agency. I am also aware that it is my responsibility to contact the Agency to check if other/more work is available. If I fail to contact the Agency. I am aware that The Agency will assume that I am not available for work.

Signature of Applicant:
Date: