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Employment Application

Important Instructions

Do not click on the forward or backward buttons on your web browser while filling out this form, otherwise all fields will be reset and your information will be erased. Fields marked with a red *star are required. Click on the "Submit Application" button at the end of the page to submit your application.  

Applicant Information

(Last, First)
No., Street, City, State, Zip


Emergency Contact Information

Name & Relationship to you
No., Street, City, State, Zip


Employment Questions

Number
(if applicable)


Education

Name of School
Name of school
Name/Type
Name of school
Name/Type
Name of school
Name/Type


Employment History

List below all present and past employers over the past ten years, starting with your most recent employer. Account for all periods of unemployment or any gaps in employment.
Name of Employer
Name & phone no.
Name of Employer
Name & phone no.
Name of Employer
Name & phone no.
Name of Employer
Name & phone no.
Name of Employer
Name & phone no.


Professional References

List three work supervisors or work related contacts who have knowledge of your work performance.


Supplemental Questions

Aventas HomeCare, LLC does not unlawfully discriminate in the provision of services or employment because of race, religion, color, sex, age, marital status, national or ethnic origin, physical or mental disability, age or any other status protected by the federal, state, or local laws. Aventas HomeCare desires to maintain a work environment that is free of sexual harassment and discrimination. Aventas HomeCare will make reasonable efforts to accommodate those physical or mental limitations of an otherwise qualified employee unless due hardship would result for the company.


Acknowledgement Section

By signing this application, I certify that I have read and completely understand the questions asked and that all answer given by me are true, accurate, and complete. I understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview may jeopardize my consideration for employment and may be cause for immediate dismissal. I further certify that I have personally completed this application.

I authorize present and former employers, all references, educational institutions and all other persons named in this application to give my any information regarding my employment, education, character, driving record or conviction record. I release Aventas HomeCare, LLC, its agents and all affiliated entities, as well as any institution that provides the Aventas HomeCare, LLC with any information about me, from any and all liability whatsoever resulting from any such investigation or disclosure of such information.

In consideration of my employment and of my being considered for employment by Aventas HomeCare, LLC, I agree to abide by all Company rules and policies, which I understand are subject to change. I also understand that if I am employed, I am an “at will employee,” employed for no definite period of time. I understand that I or Aventas HomeCare, LLC can terminate my employment at any time, with or without cause. I further understand that no communication, whether oral or written, by any representative of the Company, can constitute a contract of employment.

Testing Authorization

If offered a position with Aventas HomeCare, LLC, I hereby agree to any legally permitted physical, psychological, competency, skill, drug, or medical test required by Aventas HomeCare, LLC as a condition of employment.

Investigation Authorization

I authorize initial and post-hire investigations into all statements and references contained in this application. Said investigation may include: OIG Exclusion List Verification, Aide Certification Verification, Vehicle Insurance Verification, Fingerprint Clearance Card Verification, Credit, Driving, Criminal background, reference checks, and other background checks.

Work Hazards

I understand that if I accept employment with Aventas HomeCare, LLC, I may be exposed to potential hazards related to the provision of homecare services within private residences or medical facilities. Such hazards include but are not limited to physical exertion related to heavy lifting, continuous motion, standing for long periods of time, and exposure to on the job chemicals such as cleaning agents and medications.

By typing my initials and my complete name below, I acknowledge that I have read and understood the policies and conditions contained herein and agree to be bound by them if employed by Aventas HomeCare, LLC.

 

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