AAA T.L.C. HEALTH CARE, INC is an Equal Opportunity Employer

Date

   

First Name

MI Last Name

Home Phone

Cell Phone Alternate Phone

Present Address

City State / ZIP

E-mail

Social Security Number D.O.B.

Age

Driver Lic. No. Exp. Date

 

Employment Desired

Position applying for:

Are you applying for?

   

Shifts Desired:

For Specialty Nurses Only:

ICU/CCU
L&D
OR
NICU
PACU
Psych
ER
Allied Professionals

If hired, on what date can you start work?

 

Personal Information

Name, address and telephone number of person to be notified in case of an accident or emergency.

Have you ever applied to work for AAA T.L.C. Health Care, Inc. before?

If yes, when?

Do you have any friends or relatives working for AAA T.L.C. Health Care, Inc.?       

If yes, state name(s) and relationship

How did you learn of this job opening?

If hired, would you have a reliable means of transportation to and from work?

       

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

Can you perform the essential functions of the position for which you are applying? 

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?

If yes, state the nature of the crime(s), when and where convicted and disposition of the case.

 

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature ofthe offense, thedate of the offense, the surrounding circumstances and the relevance of the offense to the position(s)applied for may, however, beconsidered.)

 

Military experience in armed forces of the U.S. or in a state militia (U.S.).

Service Branch

 

Final Rank

Initial Rank

 

Speciality

Education, Training and Experience

School

Name and Address

Did you Graduate?

No. Years Complited

Degree Diploma

High School

Vocational/ Business

College/ University

Graduate

Can you furnish records of completion of schools and/or courses as indicated above?

   
Indicate any foreign languages you can speak, read and/or write, if relevant to the job you areseeking.
 
Fluent
Good
Fair
 
Speak
 
Read
 
Write
 
         

Do you have any other experience, training, qualifications or skills, which you feel make you especially
suited for work at AAA T.L.C.? If so, please explain:

List professional, trade, business or civic activities and offices held.

Note: You may exclude memberships, which would reveal sex, race, color, religion, national origin, age,ancestry, medical condition sexual orientation, disability or any other legally protected status.

   
 

 

Professional License and Certification

 
Answer the following if you are applying for a professional position
 

Are you licensed/certified for the job applied for?

 

Professional Lic. No.

Exp. Date

 

State

Type of Lic.

 

Professional Lic. No.

Exp. Date

 

State

Type of Lic.

 

Professional Lic. No.

Exp. Date

 

State

Type of Lic.

 

Has your license/certification ever been revoked or suspended?

If yes, state reason(s), date of revocation or suspension and reinstatement:

 

 

PLEASE CHECK CERTIFICATIONS HELD:

BCLS/CPR ACLS PAL NRP
IV CERT MAB LA FIRE & SAFETY CARD    

 

Employment History

I understand consideration for employment with AAA T.L.C. will be contingent upon the results ofreference and criminal background checks. I authorize AAA T.L.C. to investigate all information I provideon this application for employment, including previousemployment, experience and educational credentials.I also give AAA T.L.C. permission to contact my former employer(s), all listed references or any otherperson who can verify the information I provide on this application. I hereby authorize and direct mycurrent and former employers and other contacted persons to respond to any questions pertaining to theinformation included on this application.

               

NAME

DATE

List below all present and past employment starting with your most recent employer (previous 5 years issufficient). Account for all periods of unemployment. You must complete this section even if attaching aresume.

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Employer

Phone

Address

Job Title

 

Ending Salary

     

Supervisor

 

Reason for Leaving

Duties

 

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Address

Job Title

 

Ending Salary

     

Supervisor

 

Reason for Leaving

Duties

 

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Employer

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Address

Job Title

 

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Supervisor

 

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Duties

 

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Employer

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Address

Job Title

 

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Supervisor

 

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Duties

 

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Employer

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Address

Job Title

 

Ending Salary

     

Supervisor

 

Reason for Leaving

Duties

 

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To

Employer

Phone

Address

Job Title

 

Ending Salary

     

Supervisor

 

Reason for Leaving

Duties

 

Note: Additional information if necessary.