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Application for Employment

JUPITER HOME HEALTH SERVICES

12200 Fairhill Rd. Suite B421 Phone: 216-242-6102 Fax: 216-243-4401

Application for Employment

PERSONAL DATA

Date Application Completed

OFFICE USE ONLY - Date of Interview

OFFICE USE ONLY - Date of Hire

Last

First

Middle

Social Security Number

Home Phone

Cellular Number

Address

City

State

Zip Code

Length of Residence

Previous Address

Address

City

State

Zip Code

Length of Residence

JOB INTERESTS

Position Applying For

How were you referred to us?

Date available for work

Anticipated Wage

Please check the specialty area(s) that best match(es) your experience/education:

Availability / Work Status

Work Status: Full Time (32 hours per week average) Part Time (less than 32 hours per week average)

EDUCATION

Circle the highest level of education completed:

1 2 3 4 5 6 7 8 9 10 11 12 High School Diploma Associates Bachelors Masters

Name of College or Undergraduate Education/School

Degree

Year Graduated

Name of College or Undergraduate Education/School

Degree

Year Graduated

LICENSE / CERTIFICATIONS / EXAMINATIONS

Type of license

State of issuance

Expiration date

License number

Any restrictions or pending actions against license?

CPR Expiration

Last physical examination

Last TB/Chest X-ray

GENERAL INFORMATION

Are you legally authorized to work in the USA?

YES NO

If you become an employee of this Agency, you will be required to provide documentation proving your eligibility to work in the USA.

Have you ever been convicted of a felony or a misdemeanor crime?

YES NO

This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.

If yes, state the basis for each conviction and the date of the conviction:

Have you ever been employed by this agency or one of its subsidiaries?

YES NO

If yes, give location and dates:

Emergency Contact

In case of emergency, notify

Phone

Relationship

WORK HISTORY

Company 1 (present or most recent employer)

Company Name

Employment Dates - From

Employment Dates - To

Company Address

City

State

Wage (Per hour)

Wage (Annual)

Describe your job responsibilities and duties

Supervisor Name

Telephone Number

May we contact?

YES NO

Reason for leaving

DISCLAIMER & SIGNATURE

In accordance with the Title VI of the Civil Rights Act of 1964 and its implementing regulation, Jupiter Home Health Services LLC (JHHS) is an EQUAL OPPORTUNITY EMPLOYER AND WILL NOT DISCRIMINATE AGAINST RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, DISABILITY, OR COMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI. In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation, JHHS WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP. In accordance with the Age Discrimination Act of 1975 and its implementing regulations, JHHS WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision of services unless age is a factor necessary in the normal operation or the achievement of any statutory objective. In accordance with the Americans with Disabilities Act of 1990 (42 USC §12101) and its implementing regulations (private employers with more than 25 agency personnel) JHHS WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical impairment that substantially limits a major life activity, or for which there is a record of impairment which causes the individual to be regarded as impaired.

The information that I have given is true and accurate to the best of my knowledge.

Applicant Signature

Date