Skip to content
Send A Referral
Set an Appointment
Give Us Feedback
Home
About Us
Services
Careers
Resources
Contact Us
Home
About Us
Services
Careers
Resources
Contact Us
Application
Personal Information
Last Name
First Name
Middle Initial
Social Security Number
Home Address
City
State
ZIP Code
Home Phone
Mobile Phone
Other Phone
Emergency Contact Information
Contact Name
Relationship
Contact Phone Number
Job Information
Position Applied For:
CNA
Clerical
HHA
Scheduler
Caregiver
Personal Service Worker
Other Position
Date Available
Check the days of the week you are available to work:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please list all holidays you are available to work
Language Skills - Other than English, please list the languages you speak:
Licenses, Certifications
Has your professional license ever been suspended, revoked, or placed under investigation?
Yes
No
If "Yes" - Please explain:
Do you have any healthcare prohibitions?
Yes
No
If "Yes" - Please explain:
CNA
License Number
Expiration Date
HHA
License Number
Expiration Date
Other
License Number
Expiration Date
Employment History
Employer #1
Facility/Employer Name
Start Date
End Date
Address
City
State
ZIP Code
Job Title
Type of Facility:
Hospital
Nursing Facility
Other
Name of
Most Recent
Supervisor
Supervisior Phone Number
May we contact your previous employer/supervisior?
Yes
No
If "No" - please explain:
Please describe your duties and any specialty areas:
Do you have supervisory explerience?
Yes
No
If "Yes" - how often:
Pay Rate/Salary
Hourly
Salary
Was this a travel assignment?
Yes
No
If "Yes" - what was the agency's name:
Are you still employed with this by this business/agency?
Yes
No
If "No" - what was your reason for leaving:
Employment History
Employer #2
Facility/Employer Name
Start Date
End Date
Address
City
State
ZIP Code
Job Title
Type of Facility:
Hospital
Nursing Facility
Other
Name of
Most Recent
Supervisor
Supervisior Phone Number
May we contact your previous employer/supervisior?
Yes
No
If "No" - please explain:
Please describe your duties and any specialty areas:
Do you have supervisory explerience?
Yes
No
If "Yes" - how often:
Pay Rate/Salary
Hourly
Salary
Was this a travel assignment?
Yes
No
If "Yes" - what was the agency's name:
Are you still employed with this by this business/agency?
Yes
No
If "No" - what was your reason for leaving:
Additional Information
Are you legally authorized to work in the USA?
Yes
No
Have you ever been convicted of a felony offense?
Yes
No
Can you pass a pre-employment drug screening?
Yes
No
How were you referred to LovingTouch?
Newspaper
Trade Publication
Job Fair
Internet
Current Employee
I understand that I
must
report all accidents to my immediate supervisor
and
LovingTouch In-Home Care
Yes
No
I understand that I must wear a uniform and all required personal protection equipment (PPE) - The penalty for not wearing PPE is disciplinary action, up to and including termination.
Yes
No
ACKNOWLEDGEMENT -
Read carefully before signing
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.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE
Initial
By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Send
Experience the LovingTouch Difference
Contact us
