Employment: Harbour Private Duty Nursing

Date of Application*

How did you hear about Harbour Private Duty Nursing?*

Position you are applying for:*

Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Cell*

Email*

Emergency Contact:*

Phone number of Emergency Contact:*

Relationship:*

Only US Citizens or Aliens who have a legal right to work in the US are eligible for employment. Can you, upon employment, submit documentation verifying your identify and legal right to work in the US?*

Yes
No

Have you ever been convicted of a crime other than a minor traffic violation?*

Yes
No

If yes, please explain:

Do you have reliable transportation?*

Yes
No

If no, please explain:

Educational Information

High School Education:

High School:

Date of Graduation:

Diploma:

Yes
No

Address of school:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Undergraduate Education:

College/University:

Diploma:

Yes
No

Degree:

Date of Graduation:

Address of school:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

College/University:

Diploma:

Yes
No

Degree:

Date of Graduation:

Address of school:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

List any other skills or qualifications to support your application:

Previous Work Experience

1.

Place of Employment:

From Date:

To Date:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Position Title:

Reason for Leaving:

Job Duties:

May we contact for References?

Yes
No

If no, reason:

Name of Reference:

First Last

Phone Number

Email Address:

2.

Place of Employment:

From Date:

To Date:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Position Title:

Reason for Leaving:

Job Duties:

May we contact for References?

Yes
No

If no, reason:

Name of Reference:

First Last

Phone Number

Email Address:

3.

Place of Employment:

From Date:

To Date:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Position Title:

Reason for Leaving:

Job Duties:

May we contact for References?

Yes
No

If no, reason:

Name of Reference:

First Last

Phone Number

Email Address:

Licensing Information (Clinical Applicants Only)

Type:

State:

Type:

State:

Type:

State:

Please answer each of the following questions:

(If you answer "Yes" to any question, provide details)

Have any disciplinary actions been taken or are any pending against you by any state license board?*

Yes
No

Please explain:

Has your license to practice in any state ever been limited, suspended or revoked?*

Yes
No

Please explain:

Have you ever been suspended or otherwise restricted from participating in any private, federal or state health insurance program (i.e.: Medicare, Medicaid)?*

Yes
No

Please explain:

To your knowledge, have you ever been the subject of an investigation by any private, federal or state agency concerning your participation in any private, federal or state health insurance program?*

Yes
No

Please explain:

Have you had any voluntary termination of professional licensure and/or registration?*

Yes
No

Please explain:

Acknowledgement, Consent & Authorization of Applicant

I understand and agree that as an applicant for employment, I have the burden of producing adequate information for proper evaluation of my competence, character, ethics and other qualifications.

All information in this application is true to the best of my knowledge and belief. I fully understand that any significant misstatement in or omission from this application may constitute cause for denial of employment or cause for dismissal from the staff in accordance with the by-laws, rules and regulations.

I authorize investigation of all statements contained herein and the employers listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release Harbour Private Duty Nursing, LLC from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of Harbour Private Duty Nursing, LLC has any authority to enter into any agreement for employment for any specified period of time, or to make an agreement contrary to the foregoing, unless it is in writing and signed by an authorized Harbour Private Duty Nursing, LLC representative. I understand that employment with Harbour Private Duty Nursing, LLC is for no specific term and can be affected y many factors including business/economic conditions, changes in laws or employment policies, conformity to work rules, job performance, etc. Employment and may be terminated by either party with or without notice or cause at any time.

Harbour Private Duty Nursing, LLC complies with the Americans with Disabilities Act of 1990. During the interview process you may be asked questions concerning your ability to perform job-related functions. If you are given a conditional offer of employment, you may be required to complete a post-job offer medical history questionnaire and/or undergo a medical examination. If required, all entering employees in the same job category will be subject to the same medical questionnaire and/or examination and all information will be kept confidential in separate files.

Harbour Private Duty Nursing, LLC conducts our business with the highest degree of safety and efficiency. We will require applicants for employment to undergo a drug screening process.

Harbour Private Duty Nursing, LLC is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. We assure you that your opportunity for employment with this organization depends solely on your qualifications.

THIS APPLICATION WILL REMAIN ACTIVE FOR 60 DAYS. ANY APPLICANT WISHING TO BE CONSIDERED FOR EMPLOYMENT BEYOND 60 DAYS SHOULD RE-APPLY.

Applicant Signature*

Date

Applicant Printed Name

First Last

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Harbour Private Duty Nursing, LLC

Application for Employment

Personal Information

Educational Information

High School Education:

Undergraduate Education:

Previous Work Experience

1.

2.

3.

Licensing Information (Clinical Applicants Only)

Please answer each of the following questions:

Acknowledgement, Consent & Authorization of Applicant