Job Application Form

* Required Information

Date *

Name

Last Name *

First Name *

Middle Name *

Maiden Name

Street Address

City *

State *

Zip *

Previous Street Address

City *

State *

Zip *

Home Number *

Cell Phone *

Alternative Phone *

E-Mail *

Social Security Number *

How did you hear about AMERICAN PRIMARY HEALTHCARE, LLC? *

Why are you interested in employment with AMERICAN PRIMARY HEALTHCARE, LLC? *

Do you have a valid driver’s license? *

Yes

No

If Yes, from what State

License number

Make & Year of Vehicle: *

Auto Insurance Co. *

Policy Number *

Have you had any moving violations in the last 3 years? *

Yes

No

If yes, please describe

Note: Upon interview, please provide a copy of your driver’s license and auto insurance policy.

AVAILABILITY

Approximately how many hours per week do you wish to work? *

Would you accept long-term assignments? *

Yes

No

Short-term assignments? *

Yes

No

Please indicate the days and times that you are available for work:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hours Available

Do you have reservations about providing services to a client with a pet(s)? *

Yes

No

Are you willing to provide service to a client that smokes? *

Yes

No

EDUCATION, LICENSES, & CERTIFICATIONS

High School

Name

City, State or Country

Graduate

Yes

No

Number of Years Completed

College

Name

City, State or Country

Graduate

Yes

No

Number of Years Completed

Type of Degree

License or Certification 2 (if applicable)

Name or Type *

Yes

No

Number *

State *

Currently Active? *

Yes

No

Expiration Date *

Has your license or certification ever been suspended or revoked *

Yes

No

If Yes, explain

PERSONAL REFERENCES

(Do not include relatives)

Name	Address	Telephone #	Relationship

SECURITY

(As a condition of employment all employees must be “bondable.”)

Please list states and counties of residence for the past seven years: *

Have you used any names or Social Security numbers other than those on this application? *

Yes

No

If so, list on

Have you been convicted of a felony and/or theft, assault, or drug related misdemeanor? *

Yes

No

If so, please describe below. A conviction is not an automatic bar from employment.

INCIDENT CITY/STATE CHARGE

Comments

WORK EXPERIENCE

(Please list present and past employment beginning with your most recent.)

(1)

From:

To:

Job Title

Name of Employer

Phone

Address of Employer

Reason for leaving

Job Duties

(2)

From:

To:

Job Title

Name of Employer

Phone

Address of Employer

Reason for leaving

Job Duties

(3)

From:

To:

Job Title

Name of Employer

Phone

Address of Employer

Reason for leaving

Job Duties

(4)

From:

To:

Job Title

Name of Employer

Phone

Address of Employer

Reason for leaving

Job Duties

May we contact your current employer? *

Yes

No

CERTIFICATION, AGREEMENT, & RELEASE

I, , hereby authorize AMERICAN PRIMARY HEALTHCARE, LLC to request and receive from all prior employers within one year of the date of this application, any and all pertinent information to my prior employment and its termination, including the reasons for such terminations. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records, and all schooling and references. I agree to indemnify and hold harmless AMERICAN PRIMARY HEALTHCARE, LLC and any of its agents or employees from all liability, which may flow from the release of such information.

I understand that if I am hired my employment will be on an at-will, per-diem basis, for no definite term. Hours cannot be guaranteed and are subject to change. As such, I understand that I will enjoy the right to terminate my employment at any time. AMERICAN PRIMARY HEALTHCARE, LLC may also terminate my employment at any time with or without cause and/or prior notice. I further acknowledge that if offered employment I will be expected to learn and abide by all Company rules, policies, and procedures. I also understand that the use of illegal drugs is strictly prohibited while employed by AMERICAN PRIMARY HEALTHCARE, LLC and I am willing to submit to random drug testing to detect the use of illegal drugs prior to and during employment. Nothing contained in this employment application or in the granting of an interview is intended or designed to constitute an offer of employment or an employment contract between AMERICAN PRIMARY HEALTHCARE, LLC, and myself.

I hereby state that all the foregoing information I have supplied in this application is a true and a complete statement of the facts. I understand that false statements contained in this application are immediate cause for dismissal.

Signature of Applicant

Date

FOR OFFICE USE ONLY

Date of interview *

Comments_ *

Reference / Employment Check

	Employment #1	Employment #2	Employment #3
Name:
Date Contacted:
Date Verified:
Results:
Verified by:

	Personal #1	Personal #2	Personal #3
Name:
Date Contacted:
Date Verified:
Results:
Verified by: