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

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