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Employment Application

Personal Information
Your Name*
First Last
Your Email Address*
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Your Home Address*
Street Address Unit / Suite Number City State Zip Code
Maiden Name
Date of Birth (Optional)
MM slash DD slash YYYY
Cell Phone*
Home Phone
Referred By
Application Date*
MM slash DD slash YYYY
Questionnaire
How did you hear about Just Like Family?*
Do you have a high school diploma or G.E.D.?*
Have you ever been convicted of a felony or misdemeanor, or do you have any pending charges against you?*
If yes, what were the charges?*
Have you ever worked for an agency?*
If yes, where?
What type of work are you expecting from Just Like Family?*
If other, please describe.
We require everyone to work at least two weekends per month. Is this acceptable to you?*
Traveling 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?*
Do you have a home phone/answering machine?*
Are 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?*
Sometimes 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?*
Many of our clients have animals in their home. Do you have any issues working in a home where animals are present?*
If yes, please specify.
Employment Information
Nursing Title*
Where did you receive your license or certification?
Date of receiving license or certification.
MM slash DD slash YYYY
License or certification number
State
Expiration Date
MM slash DD slash YYYY
Private Duty Nursing
Nursing Home
Charge Nurse
Supervisor
List any special qualifications and/or certifications.
Do you have a valid driver's license?*
License #
PA resident since*
Year and make of your auto.
Who is your auto insurance carrier?
Inspection Expiration Date
MM slash DD slash YYYY
Have you ever been convicted of a felony or misdemeanor?*
If yes, please provide details.
Why do you want to work for Just Like Family Home Health Care Services?*
Work Availability
Date I Can Start*
MM slash DD slash YYYY
Hours You Are Available for Work*
Please enter what hours you are available for work each day of the week. (ex. 8am-4:30pm)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
If other than above, please specify.
How many total hours per week are you available?
Are you punctional?*
Do you work well with others?*
Did you ever work or apply here before?*
Qualifications and Experience
High School Name*
Number of Years*
Diploma or G.E.D.?*
Name of College
Number of Years
Diploma or Certificate?*
Nursing School Name
Number of Years
Diploma or Certificate?*
Technical Training
Number of Years
Diploma or Certificate?
Briefly describe your experience in the health care field.*
Employment History
(List most recent first.)
Employer*
Phone*
Position
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Supervisor
Address
Salary
May we contact employer?
Reason for leaving
Add Another Employer
- Yes
Employer*
Phone*
Position
Start date
MM slash DD slash YYYY
End date
MM slash DD slash YYYY
Supervisor
Address
Salary
May we contact employer?
Reason for leaving
Add Third Employer
- Yes
Employer
Phone
Position
Start date
MM slash DD slash YYYY
End date
MM slash DD slash YYYY
Supervisor
Address
Salary
May we contact employer?
Reason for leaving
References
Name of Reference 1*
Phone*
Title
Relationship*
Years known*
Name of Reference 2
Phone
Title
Relationship
Years known
Emergency Contact
Name of Emergency Contact*
Phone*
Work Phone
Address*
Relationship*
Upload Your Resume
Accepted file types: pdf, doc, docx, Max. file size: 24 MB.
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.
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Just Like Family Home Health Care Services | 845 Tuck Street, Lebanon, PA 17042 | (717) 273-1950 | Toll Free: (877) 674-9237

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