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Co-Pay/Skilled Services Payment

Application For Employment

Pinnacle Home Healthcare, Inc. offer equal employment opportunities regardless of sex, age, race, color, religion, nationa origin, ancestry, marital status, medical condition, physical or mental disability, pregnancy, or sexual orientation.

Personal Data

Last Name:   First:    M.I.: 

Address:    

City:   State:    Zip: 

Phone#:   Cell#:    Fax: 

Email: 

Will you, after an offer of employment, submit:
     Proof if your legal right to work in the United States? 
     Proof that you are at least 18 years of age? 

Are you able to perform the essential functions of the position for which you are applying, either with or without reasonable accommodations? 

If necessary, please describe what type(s) of reasonable accommodations are needed:

Contact Information In Case of Emergency

Name: 

Address:    

City:   State:    Zip: 

Phone#:   Cell#:    Relationship: 

Position

Position Desired: 

Position(s) applied for:  1st Pref:    2nd Pref: 

Salary Requirement: 

Specify:   Full-time    Part-time   Per Diem  Are you able to work overtime?  

Shift preferred:     If part-time days and hours available:  

How did you hear about PHHI:   Newspaper ad    Friend   Employee(state employee's name in other)

Other (specify):  

If an offer were extended, when would you be available for work?: 

Do you have a reliable method of transportation to and from work?  

Skills Inventory

Check if you have experience in the following

 Assisted Living Facility ICU/CCU Oncology Rehabilitation  Wound Care
Cardiac Rehab Intermediate Care Operating Room Respiratory  Wound Vac.
Education Isolation Orthopedics Skilled Nursing Facility/TCU  
Emergency Room Med/Surg Pediatrics Surgery  
Home Health Neurology/Neurosurgery Physician Practice Telemetry  
Hospice OB/Gyn/Nursery  Psychiatric Urology  

Check if you have experience in the following

MS WORD:         MS Excel:        MS Powerpoint:    Other: 

Typing Speed (wpm): 

Are you certified in CPR/ALS:     If Yes, expiration date: 

Do you read, write or speak any language other than English? 

If yes please describe: 

Professional and Technical Applicants Only

Professional License Number Type of Issue Place of Issue Exp. Date

Membership in professional organizations which may be applicable to the position you ar applying for:

Education

Please indicate the name under which you are enrolled, if different from current name: 

Month/Yr Received Name/Address of School Years Attended Course/Major Degree/Diploma
High School
College/University
Trade School
Continuing Education
Special Courses

Employment History

Most be completely filled out:

Are you currently employed:     May we contact present/previous employer?

Other names under which you have worked: 

List ALL work history beginning with the most recent job.

Job #1

From (Mo./Yr) To (Mo./Yr)  Name and Address of Employer
Name: 
Starting Salary Ending Salary Address: 
 
Supervisor City/State/Zip: 
Name:  Phone: 
Title:  Hours/wk: 
Job title and Duties:

Job #2

From (Mo./Yr) To (Mo./Yr)  Name and Address of Employer
Name: 
Starting Salary Ending Salary Address: 
 
Supervisor City/State/Zip: 
Name:  Phone: 
Title:  Hours/wk: 
Job title and Duties:

Job #3

From (Mo./Yr) To (Mo./Yr)  Name and Address of Employer
Name: 
Starting Salary Ending Salary Address: 
 
Supervisor City/State/Zip: 
Name:  Phone: 
Title:  Hours/wk: 
Job title and Duties:

List ANY periods of unemployment during the past seven years, beginning with the most recemt.

From (Mo./Yr) To (Mo./Yr) Reason for Unemployment

Please use the space below for any additional information recessary to describe your full qualifications, including accomplishments in areas that may be an asset to the position you are seeking.

Application Signature

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION FORM.

I hereby certify that the information contained in this application form is true and correct and agree to have any of the statements checked by PHHI unless I have indicated to the contrary. I authorize the references listed above, to provide PHHI with information concerning my previous employment. I hereby understand and authorize direct contact with the HR department and any immediate supervisor.

I understand that any misrepresentation, falsification, or material omission of information may result in my failure to receive an offer or if I am hired, in my immediate dismissal from employment.

Application will not be considered submitted without signature. Entering your full name is considered your signature.

Please sign below. Then click "Submit".

Click here to download the Professional Reference Request form.