Logo   Application for Employment

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis
including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

This form is to be completed online. For a printed application, please go to this link: application

Required Information   Must be completed to submit application.
Application Request for:
   Kearney, NE area      Grand Island, NE area      Southeast South Dakota
Name (First & Last)   Date  
Address     City  

    State       Zip  
Primary Phone   Secondary Phone
Email Address  
Position applying for   Date Available  

Additional Information
Have you ever worked for HeartPrint Home Care before? If yes, when?
     
Emergency Contact
Phone
Do you have dependable transportation?
 
Do you have auto insurance?
 
Can you pass a pre-employment drug test?
 
Have you ever been convicted of a felony? If yes, please provide details
     
Are there any court actions pending? If yes, please provide details.
     
How were you referred to HeartPrint Home Care? (Newspaper, Job Fair, Internet Site, Job Service, Company Employee- list name, etc)

Availability
Number of hours you would like to work
 
Times you are available to work
 
Any times not available to work
 
Can you be called at the last minute in case of emergency?   Can you work every other weekend?
 
Can you work rotating holidays?
 
Comments

Education
High School
 
City/State
Dates
College
City/State
Dates
Other
City/State
Dates
Are you or have you ever been a:
  CNA   LPN   RN       Certification Number     Expiration Date  
Has your professional license ever been suspended, revoked or under investigation? If yes, please explain
     
Are you or have you ever been a Certified Medication Aide?
      Certification Number     Expiration Date  
Do you have any other certifications (CPR, First-Aide, etc)? If yes please provide certification type(s), number(s), and expiration date(s)
     
Degrees/Certificates
Special skills or courses

Experience
Discuss any training or experience working with the elderly
What would you like most about working with the elderly?
What would you like least about working with the elderly?
List experience with performing these duties: light housekeeping, meal preparation, transportation, providing personal cares (bathing, dressing, toileting)
List any of the previously mentioned tasks you could not perform
Can you lift 50-60 pounds?
 

Employment History
    Previous Facility Types Worked.   Check All That Apply:
 
Start with your current / most recent employment and work backwards. Please go back at least five years and include all previous experiences working with the elderly.
Company
From
To
Job title
Reason left
Duties
May we contact? If no, why?
   
If your name was different, please list name on employment record
Supervisor
Phone
 
Company
From
To
Job title
Reason left
Duties
May we contact? If no, why?
   
If your name was different, please list name on employment record
Supervisor
Phone
 
Company
From
To
Job title
Reason left
Duties
May we contact? If no, why?
   
If your name was different, please list name on employment record
Supervisor
Phone
 
Company
From
To
Job title
Reason left
Duties
May we contact? If no, why?
   
If your name was different, please list name on employment record
Supervisor
Phone

Professional References
These are people you have worked with in a professional manner: co-workers, community projects, etc.
Name
Address
Relationship/Years Known
Phone
Name
Address
Relationship/Years Known
Phone
Name
Address
Relationship/Years Known
Phone
Name
Address
Relationship/Years Known
Phone

Personal References
These are your family members, friends, neighbors, etc.
Name
Address
Relationship/Years Known
Phone
Name
Address
Relationship/Years Known
Phone
Name
Address
Relationship/Years Known
Phone
Name
Address
Relationship/Years Known
Phone

ACKNOWLEDGEMENT (Please read carefully and sign):

    In signing this application I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment if revealed after employment commences.

    I give Heartland Home Care Inc. (trade name HeartPrint Home Care) permission to use any information in this application to enable the company and agents acting on the company's behalf to verify the information contained in this application. I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by HeartPrint Home Care with regard to any of the subject covered by this application. I also understand that in connection with my application for employment or my employment, HeartPrint Home Care will conduct a criminal background investigation and that my employment will be contingent on the result of such investigation. I release HeartPrint Home Care, its agents and affiliated entities as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

    In consideration of my employment and of my being considered for employment by HeartPrint Home Care, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either HeartPrint Home Care or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of HeartPrint Home Care, at any time, can constitute a contract of employment. No representative or agent of HeartPrint Home Care has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

    I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

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