Careers Form

* Required Information

Personal Information

Last Name *

First Name *

Middle Name

Position

Type of Employment *

Full Time

Part Time

Referred By *

Social Security Number *

Shift Desired *

Home Address *

City *

State *

Zip *

Home Phone *

Cell Phone *

Emergency Contact Name *

Phone *

Are you eligible for employment in the United States?

Yes

Are you 18 years of age or older?

Yes

Do you have valid driver's license?

Yes

Do you have automobile insurance? **Reliable transportation is required**

Yes

Have you ever served in the US military?

Yes

Do you have friends or relative employed by Staff Of Life?

Yes

Name

Relationship

Can you lift, turn and move patients?

Yes

Have you ever been convicted of any laws other than minor traffic violations?

Yes

Give details

Do you have a high school diploma or equivalent?

Yes

Application Confidentiality Statement

Please read each statement carefully before signing

I understand that this application is not a promise of employment. I understand that if I am hired, my employment will be for no definite period, regardless of the period of payment of wages. If accepted for employment, I agree to abide by all policies and procedures. I further understand that I have the right to terminate my employment at any time with or without notice, and Staff Of Life has the same right. No one other than the Executive Director of Staff Of Life has the authority to modify this relationship or make any agreement to the contrary. Any such notification or agreement must be in writing.

I understand that employment by Staff Of Life and the signing of this statement does NOT constitute a contract of employment or guarantee employment for specific length of time.

I understand that the company will investigate criminal background record and may investigate my driving record. As a part of the hiring process, Staff Of Life will be checking references. Staff Of Life may ask questions relating to work experience and opinions that are useful in making hiring decision. Staff Of Life may contact the references listed and may contact past employers and other named in this application to ask any questions relating to work experience and opinions useful to hiring decision. I authorize and release those employers to disclose to the company all records regarding my employment with them. I agree to release this person from legal liability in providing a statement.

Applicant Name *

Date *

Employment History

First Employer

Date Employed

Address

City

State

Zip

Phone

Starting Pay Rate

Ending Pay Rate

Title/Duties

Supervisor Name and Title

Reason for leaving

Second Employer

Date Employed

Address

City

State

Zip

Phone

Starting Pay Rate

Ending Pay Rate

Title/Duties

Supervisor Name and Title

Reason for leaving

Third Employer

Date Employed

Address

City

State

Zip

Phone

Starting Pay Rate

Ending Pay Rate

Title/Duties

Supervisor Name and Title

Reason for leaving

Education Record

High School

Name

City

State

Year Graduated

Business or Technical School

Name

City

State

Dates Attended

Undergraduate College

Name

City

State

Dates Attended

Graduate School

Name

City

State

Dates Attended

Employment Agreement

For and consideration of employment of me by Staff Of Life, I do hereby acknowledge and agree as follows: That, during the term of my Employment with Staff Of Life and for one hundred eighty days (180) days after the date of termination, for any reason, of my employment with Staff Of Life, I will not directly or indirectly become employed by any facility I provided services to as an employee of Staff Of Life.

Applicant Name *

Date *

Employee Handbook

I, have received a copy of Staff Of Life Nurse Agency employee handbook and will follow the policies during my employment with this agency.

Applicant Name *

Date *

Position Description

I have received a copy of the position description for my personal records and I understand that it is my responsibility to read and understand the agencies position description.

Applicant Name *

Date *

Resident Rights

I have received a copy of the Resident Rights for long term care facilities and In Home Client Rights. I understand their right and will abide by them.

Applicant Name *

Date *

Employment Reference Letter

Date

Phone

Applicant Name

Social Security Number

Was Employed

From

In the Position of

Reason for Leaving

I authorize you to release any and all employment reference information.

Applicant Name

Date

Phone

Applicant Name

Social Security Number

Was Employed

From

In the Position of

Reason for Leaving

I authorize you to release any and all employment reference information.

Applicant Name

HEDDINGTON OAKS POLICY

As stated in Heddington Oaks contract agency employees attempting to call off less than 2 hours to the start of a shift will have 4 hours deducted from your pay check due to late call in.

I, have read and understand the call in policy for Heddington Oaks.

Employee Name *

Date *

FACILITY CALL OFF POLICY

As stated in our contracts per facility agency employees attempting to call off less than 2 hours to the start of a shift will have 2 hours deducted from your pay check due to late call in.

I, have read and understand the call in policy.

Employee Name *

Date *

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