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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