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APPLICATION FOR EMPLOYMENT

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

PERSONAL
Last Name
First Name
Middle Name
Date of Birth
Language
Street Address
City
State
Zip Code
Phone
Email
How many hours a week are you available for work?
Have you previously applied for employment with Global Care of Massachusetts?
Are you legally eligible for employment in the United States?
How did you learn of our organization?
Scheduling Preference:
Position applying for: (ex: LPN, RN, HHA)
Therapist (Specify speciality)
EDUCATION
High School
Address
Did you graduate?
Vocational School or Certificate Programs
Address
Major or Concentration
Did you graduate?
College
Address
Major or Concentration
Did you graduate?
Employment History
Please list the last 5 years employment history, starting with your most recent employer.
Company Name
Telephone
Address
Job Title
Duties
Starting Pay
Dates of Employment From
To
Reason for Leaving
May we contact them for a reference?
_______________________________________________
Company Name
Telephone
Address
Job Title
Duties
Starting Pay
Dates of Employment From
To
Reason for leaving
May we contact them for a reference?
_______________________________________________
Company Name
Telephone
Address
Job Title
Duties
Starting Pay
Dates of Employment From
To
Reason for leaving
May we contact them for a reference?
_______________________________________________
Company Name
Telephone
Address
Job Title
Duties
Starting Pay
Dates of Employment From
To
Reason for leaving
May we contact them for a reference?
_______________________________________________
Company Name
Telephone
Address
Job Title
Duties
Starting Pay
Dates of Employment From
To
Reason for leaving
May we contact them for a reference?
_______________________________________________
Was your last name different from your present name during the above listed jobs?
If yes, what was your name?
Are you currently employed?
Do you have reliable transportation?
PROFESSIONAL REFERENCES
Name
Telephone
Email Address
Best Time To Contact
_______________________________________________
Name
Telephone
Email Address
Best Time To Contact
_______________________________________________
Name
Telephone
Email Address
Best Time To Contact
GENERAL
Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Health Agency?
If yes, please describe in full. Conviction will not necessarily disqualify an applicant from employment.
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Are you capable of performing the duties described in the job description?
If you answered no, please explain.
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Credentials, Specialized Skills, Qualifications and Equipment Operated
List any pertinent licenses including issuing authority, expiration date, and state where it was issued. Summarize any special job-related skills and qualifications gained from previous employment or other relevant experience.
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I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and herby give my full permission for Global Care of Massachusetts to contact and fully discuss my background and history with all persons and entities listed above to give Global Care of Massachusetts any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to Global Care of Massachusetts.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should contact Global Care of Massachusetts as to whether or not applications are being accepted at that time.
Nameyour full name
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