Join Our Team – Providence Home Care of Florida

Employment Application

1 Personal Information

2 Employment Information

3 Work Experience

4 Education

5 References

6 Agreement

Today's Date

PLEASE READ:
We ask that you please take some time, and put some thought into filling out your job application completely, and correctly. The majority of our applications are for PRN Clinical Field jobs. A major component of our Field Staff's job is to fill out forms online. We are most likely to contact applicants that submit complete, accurate applications.

Your completed job application should stand on its own: please DO NOT write "see résumé" anywhere on this job application.

Thank you in advance for your time.
First Name*
MI
Last Name*
Address*
Street Address City State ZIP Code
Cell Phone*
It is important that we are able to contact you via telephone, please check for errors/typos.
Email*
Enter Email Confirm Email

Also important, please check for errors/typos.

Most Recent Experience (1)
Per industry regulations, we are required to verify your employment with two previous employers.
Company name*
Position / Job Title*
Address*
City State
Supervisor's Name, Title & Positon*
Supervisor's Telephone Number
Type of Business*
Telephone Number
Employed From*
Employed To*
Starting Pay
Final Pay
Termination*
- Voluntary
- Involuntary
- Still Employed There
Briefly describe your major duties & reason(s) for termination*

Please be sure to include duties and details that you believe may relate to the job you are applying for. We are a Medicare-Certified Home Health Agency.
Most Recent Experience (2)
Per industry regulations, we are required to verify your employment with two previous employers.
Company name*
Position / Job Title*
Address*
City State
Supervisor's Name, Title & Positon*
Supervisor's Telephone Number
Type of Business*
Telephone Number
Employed From*
Employed To*
Starting Pay
Final Pay
Termination*
- Voluntary
- Involuntary
- Still Employed There
Briefly describe your major duties & reason(s) for termination*

Please be sure to include duties and details that you believe may relate to the job you are applying for. We are a Medicare-Certified Home Health Agency.
Most Recent Experience (3)
Company name
Position / Job Title
Address
City State
Supervisor's Name, Title & Positon
Supervisor's Telephone Number
Type of Business
Telephone Number
Employed From
Employed To
Starting Pay
Final Pay
Termination
- Voluntary
- Involuntary
- Still Employed There
Briefly describe your major duties & reason(s) for termination

Please be sure to include duties and details that you believe may relate to the job you are applying for. We are a Medicare-Certified Home Health Agency.
Unemployment
Account for all periods of time, three months or more, between positions held or after school
From
To
How did you spend this time?
From
To
How did you spend this time?

Education
High school or Preparatory school*
Please type the name of the school, as well as the City and State.
Major Subject (HS or Prep)
Did You Graduate (HS or Prep)*
- Yes
- No
Type of Degree or Diploma (HS or Prep)
College / University
Please enter the name of the school. If you did not attend, enter (did not attend).
Major Subject (College)
Did You Graduate (College)
- Yes
- No
Type of Degree or Diploma (College)
EXAMPLE - Associate's, Bachelor's, Master's, etc
College/University (2) or Graduate School
Major Subject (College 2 or Graduate School)
Did You Graduate (College 2 or Graduate School)
- Yes
- No
Type of Degree or Diploma (College 2 or Graduate School)
EXAMPLE - Associate's, Bachelor's, Master's, etc
Other Education
Major Subject (Other Education)
Did You Graduate (Other Education)
- Yes
- No
Type of Degree or Diploma (Other Education)
EXAMPLE - Associate's, Bachelor's, Master's, etc
Professional Designations
Designation
Organization Granting Designation
Date Completed
Designation
Organization Granting Designation
Date Completed
Professional Licenses
Type of License
State Granting License
License Number
Type of License
State Granting License
License Number
Are you bilingual?
We may service patients who do not speak English. Therefor, it may be helpful for us to have bilingual staff.
What additional languages do you speak?*

References
Please list three professional references
1 - Name*
1 - Relationship*
1 - Company*
1 - Phone*
2 - Name*
2 - Relationship*
2 - Company*
2 - Phone*
3 - Name*
3 - Relationship*
3 - Company*
3 - Phone*
Other Info
Please use the space below to share any other information about yourself, or your work experiences, that you believe to be relevant to the job for which you are applying.

PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION
I have submitted the attached form to the company for the purpose of obtaining employment. I acknowledge that the use of this form, and my filling it out, does not indicate that any positions are open, nor does it obligate the company to further process my application.

My signature below attests to the fact that the information that I have provided on my application, resume, given verbally, or provided in any other materials, is true and complete to the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the Company’s employ.

I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with the Company in the position I am seeking.

I understand that this application is not an employment contract for any specific length of time between the Company and me, and that in the event I am hired, my employment will be “at will” and either the Company or I can terminate my employment with or without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or any obligation on the Company’s part. The Company may, at its sole discretion, hold in abeyance or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process affecting its employees.

References: I hereby authorize the company and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form. Furthermore, I authorize the company and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications.

Temporary/Contract Employment: If employed as a temporary or contract employee, I understand that I may be an employee of the company and not of any client. If employed, I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. I further understand that a contract will exist between the company and each client to whom I may be assigned which will require the client to pay a fee to the company in the event that I accept direct employment with the client, I agree to notify the company immediately should I be offered direct employment by a client (or by referral of the client to any subsidiary or affiliated company), either for a permanent, temporary (including assignments through another agency), or consulting positions during my assignment or after my assignment has ended.
Signature*

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Today's Date
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Employment Application

Most Recent Experience (1)

Most Recent Experience (2)

Most Recent Experience (3)

Unemployment

Education

Professional Designations

Professional Licenses

References

Other Info

PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION