We are seeking professional caregivers to join our team!Complete Application Below to Apply : Todays Date * MM DD YYYY Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * How Did You Hear About Us? * Google Facebook Instagram Health Fair Other Subject * Phone * (###) ### #### Alt Phone (###) ### #### Position Appling For: * Registered Nurse (RN) Licensed Practical Nurse (LPN) CNA or PCA Homemaker Companion Scheduler Office Support Staff When Are You Available to Start? * MM DD YYYY Are you legally eligible for employment in the United States? * Yes No Can you present a government issued ID and social security card in person? Yes No Do you understand that background checks and drug tests are required for employment? * Yes No Have you ever been convicted of a crime or violation other that a minor traffic infraction? * Yes No Do you have any current indictments and / or pending criminal charges against you? * Yes No Please Explain any convictions/ Current or pending indictments or charges other than a minor traffic in fraction. * In case of emergency notify: * First Name Last Name Emergency contact phone number: * (###) ### #### Relationship * In case of emergency notify: * First Name Last Name Emergency contact phone number: * (###) ### #### Relationship * PROFESSIONAL INFORMATION License/ Certification Type * CNA HHA PCA LPN RN No License or Certification Profession License/ Certification Number * Have a license / certification ever been issued in another state? * Yes No State Issued * License/ Certification Expiration Date * MM DD YYYY Do you have CPR/ BLS? * Yes No Can You Provide Proof of Negative TB done within past 12 months? * Yes No Can you lift/ turn 50 pounds without assistance? * Yes No Do you have IV Certification? * Yes No N/A for my role Has your professional license or certification ever been subject to disciplinary action by state board or body? * Yes No Are you currently working under a restricted license or certification? * Yes No Do you have any pedning complaints or investigations against your professional license / certification in any state? * Yes No Please Describe or place N/A Do you have any restrictions that would prevent you from performing essential functions of the role you are applying for? * Yes No Please Describe or place NA. If accommodations are needed to complete job related tasks, please explain what accommodations would be needed. Do you have professional liability insurance? * Yes No In the past two years, have you lived outside of the United States? * Yes No Past 5 Years Work History Previous or Current Employer 1 * Position you were employed for * Start Date * MM DD YYYY End Date- Use Todays Date if Still Employed * MM DD YYYY Phone of Current/ Previous Employer 1 * (###) ### #### Previous Employer Email May We Contact Employer? * Yes No Previous Employer 2 * Position you were employed for * Start Date * MM DD YYYY End Date- Use Todays Date if Still Employed * MM DD YYYY Phone of Previous Employer * (###) ### #### Previous Employer Email May We Contact Previous Employer? * Yes No Previous Employer 3 * Position you were employed for * Start Date * MM DD YYYY End Date- Use Todays Date if Still Employed * MM DD YYYY Phone of Previous Employer * (###) ### #### Previous Employer Email May We Contact Previous Employer? * Yes No Previous Employer 4 * Position you were employed for * Start Date * MM DD YYYY End Date- Use Todays Date if Still Employed * MM DD YYYY Phone of Previous Employer * (###) ### #### Previous Employer Email May We Contact Previous Employer? * Yes No Previous Employer 5 * Position you were employed for * Start Date * MM DD YYYY End Date- Use Todays Date if Still Employed * MM DD YYYY Phone of Previous Employer * (###) ### #### Previous Employer Email May We Contact Previous Employer? * Yes No Professional Reference * First Name Last Name Professional Reference Email Professional Reference Phone * (###) ### #### Personal Reference * First Name Last Name Personal Reference Phone * (###) ### #### Personal Reference Email ACKNOWLEDGEMENT & CONSENT * (please read carefully and sign below) I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I agree that, if hired, I may be discharged from employment if Apex VIP Care, LLC learns of any falsification or material omission in the information I have provided and if discovered prior to hire, I would be ineligible for consideration if you have been convicted of a position, as well. (NOTE: You will not automatically be excluded from consideration if you have been convicted of a crime. Your suitability for the position sought will be evaluated based upon the totality of circumstances such as the crime, the recency of the conviction, the type of work involved, etc.). I understand and agree that all information concerning patients and their families is strictly confidential. I am not permitted to disclose any financial, medical or personal information related to any patient or family member to fellow employees, company administrative staff or individuals, except my supervisor at Apex VIP Care, LLC. I authorize Apex VIP Care, LLC to investigate my employment history, credentials, license verification and to obtain any relevant information, including a criminal background check needed to make an employment decision. I authorize Apex VIP Care, LLC to disclose this application along state, federal, contractual or accreditation audit purposes. I also authorize Apex VIP Care, LLC to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release Apex VIP Care, LLC and any information. I also understand and agree that passing a medical examination (which is my responsibility) and/or medical screening may be required. If medical restrictions cannot be reasonable accommodated, I may not be hired, or if hired, I may be terminated. I understand and agree that I may be subject to pre-employment drug testing and/or alcohol testing, random testing, as well as testing where reasonable suspicion or improper usage has occurred, or where warranted by an on-the-job injury, circumstance, workplace conditions or contractual requirements. I understand and agree nothing contained in this employment application or in granting of an interview creates an employment contract between Apex VIP Care, LLC and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be "at-will;" that is, I will have the right to terminate my employment at any time and that Apex VIP Care, LLC retains the same right to terminate my employment at any time. I understand that should I become employed by Apex VIP Care, LLC retains the same right to terminate my employment at any time. I understand that should I become employed by Apex VIP Care, LLC my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of Apex VIP Care, LLC. I understand that Apex VIP Care, LLC is committed to promoting safety and high standards of employee performance, productivity and reliability. In order to achieve this, I may be subjected to a drug test prior being hired to assure Apex VIP Care, LLC do not currently have narcotics, sedatives, stimulants or other controlled substances and/or mood-altering substances in my body. I understand if I have any such substance in my body at the time of the drug test, Apex VIP Care, LLC will not hire me. I understand that Apex VIP Care, LLC reserves the right to add to, change and/or delete their policies, procedures, work rules and benefits at anytime and that no one in Apex VIP Care, LLC has the authority to enter into an agreement for any particular period of time, or contrary to the above terms, unless that agreement is set forth in writing and signed by an authorized representative of Apex VIP Care, LLC. I acknowledge, I have read and understand the contract terms and conditions stated above. Click here to Acknowledge Type Name for Digital Signature * Your application for Apex VIP Care has been received and will be reviewed soon. We will reach out to you if we would like to move forward with the next steps. Thank you!
