Careers


    We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

    PERSONAL INFORMATION

    First

    Middle

    Last

    Social Security No

    Date of Birth

    Present Address

    City

    State

    Zip

    Are you 18 years or Older?
    YesNo

    Primary Phone

    Secondary Phone

    DESIRED EMPLOYMENT

    Position applied for

    Date you can start

    Wage Desired

    Are you employed now ?
    YesNo

    Email Address

    Who referred you to this company ?

    Enter days & Times Available

    LICENSURE / CERTIFICATION

    License Type

    License/Certification No

    State

    Expiration Date

    CPR Expiration Date

    Last TB Date

    First Aid Certification Date

    Hepatitis B series (y/N & date)
    YesNo

    EDUCATION

    School
    RNCNALPNOther

    Name and Location of School

    # Years Attended

    Did you Graduate?
    YesNo

    Subjects Studied

    College

    Location of School

    # Years Attended

    Did you Graduate?
    YesNo

    Subjects Studied

    Trade, Bussiness & Correspondance School

    Name & Location of School

    # Years Attended

    Did you Graduate?
    YesNo

    Subjects Studied

    GENERAL INFORMATION


    Please list any other work related informaton you think would be helpful to us in considering you for employment such as foreign language, additional work experience, volunteer work, accomplishments, Publications etc..

    Special Training

    Special Skills

    FORMER EMPLOYERS

    List Your last three employers, starting from last recent first

    Employer Name

    Address

    City

    State

    Zip Code

    Starting Date

    Leaving Date

    Job Title

    Hourly Starting Salary

    Hourly Final Salary

    May we contact your supervisor
    yesNo

    Name of Supervisor

    Title

    Phone

    Description of work

    Reason of leaving

    Employer Name

    Address

    City

    State

    Zip Code

    Starting Date

    Leaving Date

    Job Title

    Hourly Starting Salary

    Hourly Final Salary

    May we contact your supervisor
    YesNo

    Name of Supervisor

    Title

    Phone

    Description of work

    Reason of leaving

    Employer Name

    Address

    City

    State

    Zip Code

    Starting Date

    Leaving Date

    Job Title

    Hourly Starting Salary

    Hourly Final Salary

    May we contact your supervisor
    YesNo

    Name of Supervisor

    Title

    Phone

    Description of work

    Reason of leaving

    PERSONAL REFERENCE

    Provide three (3) professional references, not related to you, who have known you atleast one (1) year.

    Name

    Address

    Relationship

    Phone Number

    Years Known

    Name

    Address

    Relationship

    Phone Number

    Years Known

    Name

    Address

    Relationship

    Phone Number

    Years Known

    EXPERICENCE WITH SENIORS & SPECIAL NEEDS POPULATIONS


    Describe any personal, volunteer or work-related experiences that will help you in this position.

    Have you had a TB test in 3 years?
    YesNo

    Have you ever been convicted of a crime?
    YesNo

    Do you have clean driving record ?
    YesNo

    Please answer the following questions

    What do you think is the most difficult part of nursing or customer service work?

    What was the best job you ever had and why?

    What was your least favorite job and what did you dislike about it?

    How will you be able to contribute to providing seniors with high quality care?

    Imagine you have been on your feet and working hard all the day. The customer you have been dealing with is rude and impatient, what do you do ?

    AUTHORIZATION

    Are you legally authorized to work in USA ?

    YesNo

    (Should you become Employed by Omega Home Care Services, you will be required to provide documentation proving your eligibility to work in USA)

    Have you ever been convicted or charged with a felony or misdimeanor crime?

    YesNo


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    If yes, what crime and dates of convictions or charges.

    (This does not apply if there was a juvenile conviction . A criminal conviction will not necessarily bar you for employment. We will consider the nature of the crime, the time that have elapsed since the occurrence and any rehabilitation you have undergone.)

    AUTHORIZATIONS - Read and put a check mark on each paragraph, and then
    sign below:

    I hereby certify that all statements made on this application are accurate and true, to the best of my knowledge and that inclusion of false information or omission of material could result in DISMISSAL of employment or REMOVAL of my application from further consideration. I also hereby certify that I am not suffering from a communicable disease or mental disorder which would hinder my job performance, nor have I been charged with or convicted of a crime involving abuse, neglect, exploitation, or deprivation of a child or adult. I hereby authorize all my employers and police/sheriff department unless otherwise stated to release any and all information in regard to my employment as requested.

    Signature

    Date