Application For Employment

Hepatitis B Immunization Acceptance or Declination

Are you eligible to work in the United States?
Yes No

Are you 18 years of age or older?
Yes No

Have you ever been employed by Infiniti Home Health Care?
Yes No

Have you ever been convicted of a crime other than traffic offenses?
Yes No

if required for position, do you have a valid driver's license?
Yes No

How did you learn about this employment opportunity?
Ad in newspaper
Job Bulletin (Posting)/Walk-in
Website
Department if Labor
Ad in magazine
Referral by employee
Other

EDUCATION

High School

Did you graduate?
Yes No

GED

Did you graduate?
Yes No

Other School

Did you graduate?
Yes No

College

Did you graduate?
Yes No

College

Did you graduate?
Yes No

College

Did you graduate?
Yes No

Other credentials/licenses/professional affiliations, etc., which are relevant to the job(s) for which you are applying

SKILLS: Please list clinical skills, technical skills, clerical skills, trade skills, etc., relevant to this position.

WORK EXPERIENCE Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission military or volunteer commitments. PLEASE DO NOT complete this information with the notation "See Resume." PLEASE NOTE Infiniti Home Health Care reserves the right to contact al current and former employers for reference information.


Dates Employed (most recent position)

From

To

Full timePart timeNo

Contact my current references
At any time Only if I am a finalist candidate

Primary duties

Dates Employed (most recent position)

From

To

Full timePart timeNo

Contact my current references
At any time Only if I am a finalist candidate

Primary duties

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or mission of facts, represents grounds for elimination form consideration for employment, or termination after employment if discovered at a later date. I authorize Infiniti Home Health Care to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit bacground investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document in NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contact for continued guaranteed employment. I understand that employees of Infiniti Home Health Care serve at-will, and the employment relationship may be terminated at any time by either party, or any no reason, other than a reason prohibited my law. If employed, I will be required to furnish proof of eligibility to work in the United States and to comply with agency regulations. I understand that the first SIX MONTHS of regular employment represent a provisional period, during which I would now be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.