AAA T.L.C. HEALTH CARE, INC is an Equal Opportunity Employer
Position applying for:
Are you applying for?
For Specialty Nurses Only:
If hired, on what date can you start work?
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.).
Education, Training and Experience
Name and Address
Did you Graduate?
No. Years Complited
Can you furnish records of completion of schools and/or courses as indicated above?
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
Are you licensed/certified for the job applied for?
Professional Lic. No.
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Has your license/certification ever been revoked or suspended?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:
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.
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.
Reason for Leaving
Note: Additional information if necessary.