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AMERICAN HOMECARE & MEDICAL SERVICES

EMPLOYMENT APPLICATION

3651 Vineville Avenue, Macon, GA 31204

APPLICANT INFORMATION

Last Name:

First Name:

M. I.

Date:

Street Address

Apartment/Unit #

City

State

Zip

Phone

Email Address

Date Available

Social Security No.

Desired Salary

Position Applied For

Are you a United States Citizen?

Yes No

If not, are you authorized to work in the U.S.?

Yes No

Have you ever worked for this company?

Yes No

If so, when?

Have you ever been convicted of a felony?

Yes No

If yes, explain?

EDUCATION

High School

Address

From To

Did you graduate?

Yes No

Degree

College

Address

From To

Did you graduate?

Yes No

Degree

Other

Address

From To

Did you graduate?

Yes No

Degree

REFERENCES: Please list three professional references

Full Name:

Relationship:

Company:

Phone Number:

( )

Full Name:

Relationship:

Company:

Phone Number:

( )

Full Name:

Relationship:

Company:

Phone Number:

( )

EMPLOYMENT HISTORY STARTING WITH YOUR PRESENT EMPLOYMENT ( 5 years work history is required)

Employer:

Phone: ( )

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Job Description:

Dates of Employment:

From: To:

Reason for Leaving:

May we contact your previous supervisor for a reference? Yes No

Employer:

Phone: ( )

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Job Description:

Dates of Employment:

From: To:

Reason for Leaving:

May we contact your previous supervisor for a reference? Yes No

Employer:

Phone: ( )

Address:

Supervisor:

Job Title:

Starting Salary:

Ending Salary:

Job Description:

Dates of Employment:

From: To:

Reason for Leaving:

May we contact your previous supervisor for a reference? Yes No

MILITARY SERVICE:

Branch

From: To

Rank at Discharge:

If other than honorable discharge, please explain:

EMERGENCY CONTACT

Name/Address

Phone Number: ( )

Alternate phone Number: ( )

DISCLAIMER AND SIGNATURE:

I certify that my answers are true and complete to the best of my knowledge. If my application leads to an employment,

I understand that false or misleading information in my application or interview may result in my release.

Signature

Date:

AMERICAN HOMECARE & MEDICAL SERVICES, LLC

3651 Vineville Avenue, Macon, GA 31204

Phone: (478) 787-6040 Fax: (478) 787-6039

APPLICATION INFORMATION

Name:

Address:

Home Phone:

Cell Phone:

EMERGENCY CONTACT

Contact #1

Name:

Address:

Home Phone:

Cell Phone:

Contact #2

Name:

Address:

Home Phone:

Cell Phone:

Contact #3

Name:

Address:

Home Phone:

Cell Phone:

I ________________________________________have not entered any false information or made any untrue statements concerning qualification requirements by American Homecare and Medical Service

________________________________________________ _________________________________

Signature Required Date

Have you ever been shown by credible evidence (a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or subjected any person to serious or minor injury as a result of intentional or grossly negligent misconduct as evidenced by oral or written statement to this effect obtained at the time of this application? Yes__________ No ____________________

If yes, please explain: ____________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

____________________________________ _______________________________

Signature Required Date

I certify that the information I have provided is complete and true, and that any misrepresentation shall be a cause for dismissal. If I am accepted for employment, I will abide by the terms of all rules and codes of conduct with my position. I, _________________________________________ hereby swear and affirm that all of the above and foregoing is true and correct to the best of my knowledge.

_________________________________________________ _____________________________________

Signature Required Date

Consent Form (Drug Testing)

I hereby consent to submit urinalysis and/or other tests as deemed appropriate by American Homecare in the application process for employment, for the purpose of determine the drug content thereof.

I authorize _____________________________________________, to collect the specimen for the test, test the specimen for the use of illegal drugs and allow them to return the results to American Homecare.

I understand that the current use of illegal drugs prohibits me from becoming employed by American Homecare.

I further agree to release American Homecare from any liability arising out of the collection of specimens, testing of specimens and use of information from testing in connection with the employer’s consideration of my application for employment.

I also agree that a copy of this Consent Form will have the same effect as the original.

I have read and understand the above information regarding my pre-employment substance abuse test. I agree that my signing this Consent Form was totally voluntary and a company official did not coerce me into doing so.

Applicant’s Name: ( print) ____________________________________________

Applicant’s Signature: ____________________________________________

Applicant’s SS # __________________ Date: ____________________

Witness Name: (print) ____________________________________________

Witness Signature: __________________ Date: ____________________

Agreement Regarding Confidentiality and Non-Disclosure

This agreement regarding Confidentiality and Non-disclosure (this “Agreement”), is made as of this ____________ day of ______________ 20____, by and between American Homecare and _____________________________: Employer”.

For and in consideration of employment by American Homecare and other good and valuable consideration the receipt and sufficiency of which are hereby acknowledged, the undersigned does hereby covenant and agree as follows:

Confidential Information and Non-Disclosure

Employee acknowledges that American Homecare is in the business of providing medical and in-home health care and a related service to individuals (the “Business”) American Homecare conducts the Business throughout the State of Georgia. Employee acknowledges that American Homecare’s business is highly specialized, that the identity and particular needs of American Homecare’s clients are not generally known in the in-home health care industry, that American Homecare has a proprietary interest in its client list, and the confidential information concerning each client, and that documents and other information concerning American Homecare including, but not limited to, its business practices, marketing strategies, sales methods, products specifications, pricing, costs and clients, the identity, location service requirements, medical needs and charges to its client (the confidential information), are highly confidential. Employee further acknowledges that the confidential information is owned and shall continue to be owned solely by American Homecare.

During the term of employment and for one year after such employment terminates for any reason, regardless of whether the termination is initiated by the Employee or American Homecare, Employee agrees not to use, Communicate, reveal or otherwise make available the Confidential Information to any person, partnership, corporation or entity other than American Homecare, unless such employee is compelled to disclose the confidential Information by judicial process.

Enforcement

Employee acknowledges that compliance with the Agreement is necessary to protect American Homecare’s Business goodwill: a breach of this Agreement will irreparably and continually damage American Homecare; and an award of money damages will not be adequate to remedy such harm. Consequently, employee agrees that in the event employee breaches or threatens to breach any of these covenants, American Homecare shall be entitled to both; (a) a preliminary or permanent injunction in order to prevent the continuation of such harm; (b) money damages, insofar as they can be determined, including, without limitation, all reasonable costs and attorney’s fees incurred by American Homecare in enforcing the provision of this Agreement. Nothing in this Agreement, however, shall prohibit American Homecare from also pursuing any other remedy.

Agreed to as of the first date written above.

___________________________________ ____________________________ __________________

Employee Name (Print) Employee Signature Date

__________________________________ ___________________________ ___________________

Witness Name (Print) Witness Signature Date

651 Vineville Avenue – Macon, GA 31204

Phone: (478) 787-6040 – Fax: (478) 787-6039

	REGISTERED NURSES & LICENSED PRACTICAL NURSES
	Georgia Nurses License (Must Verify Original Copy)
	Current BLS – American Heart Association (Must Verify Original Copy)
	PPD within the 12 months (Must have documentation of Negative PPD)
	Chest X-ray within the last 5 years if PPD is positive (proof of +PPD and CXR required)
	Drivers License (Must Verify Original Copy)
	Social Security Card, Birth Certificate, or Passport
	Resume- Work experience must be current and show 5 years of experience of what you will be working
CERTIFIED NURSING ASSISTANT
Certified with the State of Georgia (Must Verify Original Copy)
Current CPR – American Heart Association only (Must Verify Original Copy)
PPD within the 12 months (Must have documentation of Negative PPD)
Chest X-ray within the last 5 years if PPD is positive (proof of +PPD and CXR required)
Drivers License (Must Verify Original Copy)
Social Security Card, Birth Certificate, or Passport
Resume- Work experience must be current and show 5 years of experience of what you will be working

OTHER REQUIREMENTS BY AMERICAN HOMECARE

Criminal Background Check

Drug Screen

Competency exam with a minimal of 75% score (Can only be taken 2 times)

Two Work References in file before working an assignment