Employment Application Personal InformationYour Name* First Last Your Email Address* Enter Email Confirm Email Your Home Address* Street Address Unit / Suite Number City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Maiden NameDate of Birth (Optional) Cell Phone*Home PhoneReferred ByApplication Date* QuestionnaireHow did you hear about Just Like Family?*Please make a selectionNewspaperPhone BookRadio/TVInternetFriendDo you have a high school diploma or G.E.D.?*Please make a selectionYesNoHave you ever been convicted of a felony or misdemeanor, or do you have any pending charges against you?*Please make a selectionYesNoIf yes, what were the charges?*Have you ever worked for an agency?*Please make a selectionYesNoIf yes, where?What type of work are you expecting from Just Like Family?*Please make a selectionStaffingPrivate DutyOther (Please describe below.)If other, please describe.We require everyone to work at least two weekends per month. Is this acceptable to you?*Please make a selectionYesNoTraveling to and from clients' homes is required. Do you have reliable transportation?* Car/Insurance Bus Rides How far are you willing to travel?*There are times when you will be required to run errands or take clients to appointments. Will you be able to do this?*Please make a selectionYesNoDo you have a home phone/answering machine?*Please make a selectionYesNoAre you willing to work at a lower skill level if work is not presently available at your level?* RN as LPN RN as CNA RN as PCA LPN as CNA LPN as PCA I am applying for a PCA position We sometimes offer shifts on short notice. Will that be a problem?*Please make a selectionYesNoSometimes we must transfer heavy clients. How do you feel about that?*Would you be willing to get a flu shot, as required by some facilities?*Please make a selectionYesNoMany of our clients have animals in their home. Do you have any issues working in a home where animals are present?*Please make a selectionYesNoIf yes, please specify.Employment InformationNursing Title*Please make a selectionRNLPNCNAPCAWhere did you receive your license or certification?Date of receiving license or certification. License or certification numberStatePennsylvaniaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificExpiration Date Private Duty NursingSelect the number of years of nursing.less than 11234567891011121314151617181920+Nursing HomeSelect the number of years of nursing.less than 11234567891011121314151617181920+Charge NurseSelect the number of years of nursing.less than 11234567891011121314151617181920+SupervisorSelect the number of years of nursing.less than 11234567891011121314151617181920+List any special qualifications and/or certifications.Do you have a valid driver's license?*Please make a selectionYesNoLicense #PA resident since*Year and make of your auto.Who is your auto insurance carrier?Inspection Expiration Date Have you ever been convicted of a felony or misdemeanor?*Please make a selectionYesNoIf yes, please provide details.Why do you want to work for Just Like Family Home Health Care Services?*Work AvailabilityDate I Can Start* Hours You Are Available for Work*Please enter what hours you are available for work each day of the week. (ex. 8am-4:30pm)MondayTuesdayWednesdayThursdayFridaySaturdaySunday If other than above, please specify.How many total hours per week are you available?Are you punctional?*Please make a selectionYesNoDo you work well with others?*Please make a selectionYesNoDid you ever work or apply here before?*Please make a selectionYesNoQualifications and ExperienceHigh School Name*Number of Years*Diploma or G.E.D.?*Please make a selectionYesNoName of CollegeNumber of YearsDiploma or Certificate?*Please make a selectionYesNoNursing School NameNumber of YearsDiploma or Certificate?*Please make a selectionYesNoTechnical TrainingNumber of YearsDiploma or Certificate?Please make a selectionYesNoBriefly describe your experience in the health care field.*Employment History(List most recent first.)Employer*Phone*PositionStart Date End Date SupervisorAddressSalaryMay we contact employer?Please make a selectionYesNoReason for leavingAdd Another Employer Yes Employer*Phone*PositionStart date End date SupervisorAddressSalaryMay we contact employer?Please make a selectionYesNoReason for leavingAdd Third Employer Yes EmployerPhonePositionStart date End date SupervisorAddressSalaryMay we contact employer?Please make a selectionYesNoReason for leavingReferencesName of Reference 1*Phone*TitleRelationship*Years known*Name of Reference 2PhoneTitleRelationshipYears knownEmergency ContactName of Emergency Contact*Phone*Work PhoneAddress*Relationship*Upload Your ResumeAccepted file types: pdf, doc, docx.Upload your resume in .pdf, .doc or .docx format.Certification“I certify that all of the information provided in this application is correct. I have not misrepresented any facts, nor have I failed to provide you with any information that is necessary in evaluating my possible employment with Just Like Family. I understand that, if employed: falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal and otherwise, and release all liability for damages that may result from furnishing same to you.” Acceptance* I agree to the certification statement above.