Access Home Health Agency

Employment - Volunteer Application
Please Read Before Completing This Application

This company does not discriminate in the recruitment on the basis of race, color, religion, national origin, sex, marital status, handicap, age or veteran status. No question on this application is intended to secure information to be used in a discriminatory manner. Your completed application will be reviewed carefully, but its receipt does not imply that you will be accepted. Consideration necessitate that you meet all minimum qualifications required of the position for which you are applying.

Personal Data (Please fill in all blanks)

Date (i.e.:09/21/06):

Volunteer Employment

Last Name:

First Name:

Middle Name:

Maiden:

Social Security #

Email:

Present Address:

Street:

City:

State:

Zip:

Home Telephone #

Work or Alt. #

Position (s) Applied for: (1)

Position # (2)

Minimum Income Requirement:

Available to start date?

If Driving is required of this position.

Do you have a reliable means of transportation?

Yes No

Do you have a current valid Mo. driver's license?

Yes No

Driver's license No.

Do you have auto liability insurance?

Yes No

Insurance Carrier:

Any objections to travel, if required by job?

If you have alien status and are hired, can you provide written evidence of your right to work in the U.S.?

Yes No

Please list any reason known to you why you might be unable to perform consistently and promptly any of the job duties:

This job may require that you be able to lift up to and including 50 lbs, are you able to do this?

Yes No

Do you have any disability that would require some sort of accommodations be made for you to do this job?

Yes No

Educational BackGround

Type of School

Name and City

Years Attended

Graduated

Course or major

High School

YesNo

Trade School/
College

YesNo

Other Training

YesNo

Have you ever served in the armed forces?

Yes No

What Branch?

Special Training or duties during services?

Work History (List in order, from present to last employer.)

From:

To:

Position Tile:

Name of Employer

Address:

Telephone # :

Summary of Job duties:

Likes about job:

Dislikes about job:

Starting Salary $

Ending Salary $

Immediate Supervisor's Name:

Title:

Reason for Wanting a job Change:

From:

To:

Position Tile:

Name of Employer

Address:

Telephone # :

Summary of Job duties:

Likes about job:

Dislikes about job:

Starting Salary $

Ending Salary $

Immediate Supervisor's Name:

Title:

Reason for Wanting a job Change:

From:

To:

Position Tile:

Name of Employer

Address:

Telephone # :

Summary of Job duties:

Likes about job:

Dislikes about job:

Starting Salary $

Ending Salary $

Immediate Supervisor's Name:

Title:

Reason for Wanting a job Change:

May we contact the employers listed on this page?

Yes No

If not, please indicate which one (s) you do not wish us to contact.

Do you hold a professional license

Yes No

What?

Have you ever been disciplined or fired?

Yes No

Why?

Have you ever pleaded guilty to a misdemeanor or felony offense or been convicted of crime?

Yes No

If yes, please provide details :

Has your professional license, if required for this position, ever been revoked or suspended?

Yes No

If yes, please explain:

We do contact all licensing boards to check status of each person employed with our company.

Is there any reason why you may not be able to accept employment, if offered, with this company?

Yes No

If yes, please explain:

Are there any other experiences, skills, or qualifications which you feel are relevant to this job that have not already been mentioned?

Availability Information

I hereby certify that the answers given by me to all the questions contained in the application form are true and correct. I understand that if any information is found to be false that I am subject to immediate dismissal at any point of my employment. If employed by the Company, I will comply with all rules, regulations, policies, procedures and standards of Access Hospice Care, Inc. I agree to submit to a physical examination, drug testing (if required), and authorize anyone to give this Company any Credit information concerning me. I also authorize my former employers to give any information they have regarding me, whether or not it is on their records. I hereby release them and any past employer from all liability for any damage whatsoever for issuing same. If upon investigation, anything in the application is found to be untrue, or if I do not pass the physical examination or drug testing (if required) I understand I will be subject to dismissal. By typing your name in the spaces provided and clicking the submit button, you are signing this document and agree to the information you provided is true.

Date (i.e.:09/21/06):

Name:

Access Home Health is a healthcare facility in Springfield, MO. We provide services to many cities in the surrounding
area. Call us today or check out one of our affiliate sites.