Application for Employment

Employment Desired

I am applying to the following branch:
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Education History

General Information

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Professional Credentials

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Former Employers

List below your last 4 employers, beginning with your most recent employment

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References

List 2 Business References and 2 Personal References

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Emergency Contact

Malpractice Insurance

If you have your own insurance, please fill out the below information

Authorization

“I certify the facts contained in the application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shell be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I understand that the consumer credit report or criminal records check may be necessary prior to my employment. If such reports are required, I understand that, in compliance with federal law, the company will provide me with a written notice regarding the use of these reports and will also obtain a separate written authorization from me to consent to these reports. I also understand that a poor credit history or conviction will not automatically result in disqualification from employment.”

In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and complete the required employment eligibility verification document from upon hire.

I give Above the Rest authorization to obtain background record checks and medical record checks.

I, hereby authorize Above the Rest Home Care LLC, to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination.

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