EMPLOYMENT APPLICATION
5517 N. Cumberland, Suite 915, Chicago, IL 60656 · 773.467.6002 · Fax: 773.467.6003
An Affiliate of Private Home Care and Pri-Med Infusion Services

 

Thank you for your interest in employment with us. Working together, our employees provide a team environment to care for the needs of the home bound patient. As a team, we have a mutual interest in helping one another achieve success on the job by consistently providing compassionate patient care, focus on a customer service orientation in all of our interactions and constant process improvement. If you concur and can demonstrate these beliefs, we encourage you to complete the application for employment.

 

We provide an equal employment opportunity without regard to race, color, religion, sex, age, national origin, disability, marital status, sexual orientation, or veteran status as required by federal, state, and local laws.

 

PLEASE COMPLETE THE FORM BELOW

* Required Fields

Personal Information

Last Name:*  
First Name:*  
Middle Name:
Street Address:*  
City:*    
State:*

Zip Code:*  
Home Phone:*  
Cell Phone:
 Work Phone:
Email Address:
 Social Security Number:
 Other Names used in work or school:
Person to contact in case of emergency:*  
Emergency Phone Number:

Position Desired and Schedule Availability

Position Desired:*

Full Time:
 Part Time:
 Week-ends:
 Holidays:
 Per Diem:
 Date available for work:
 Shift Preference:
Note: Work schedules are based upon the needs of the business and may be subject to change.
Can you perform all the essential job-related functions of the position for which you are applying?
If “no”, please explain: 

Education:

Level of
 Education		 Name and Address
 of school		 Number of years
 completed		 Did you
 graduate?		 Major of study
High School
GED
Business or Trade
College
Other Formal Training:  
List any additional information necessary to describe your full qualifications and skills relevant to the position for which you applied:

Current Professional Registration, License or Certification:

Type of License and/or Certification: Issued By: License or
Certification Number:		 Expiration Date:
Has your professional license every been revoked, suspended or put on probation?         

Employment History:

In the following spaces give a complete record of your employment including periods of unemployment, if any. Begin with your most recent employment and work backward. If additional space is needed, attach a supplementary sheet or resume.
Name of Current or Last Place of Employment:*  
Telephone Number:*  
Street Address:*  
City:*        
State:*
Zip Code:*  
Job Title:*  
Explain Job Duties:
Date Started (M-D-Y):*  
Date Left (M-D-Y):*  

Starting Pay:
 Final Pay:
Name of Immediate Supervisor:
 Supervisor’s Title:
May We Contact:
Yes No If No, Why?
Reason for Leaving:
Name of Current or Last Place of Employment:
 Telephone Number:
Street Address:
City:
 State:
Zip Code:
Job Title:
 Explain Job Duties:
Date Started (M-D-Y):
 Date Left (M-D-Y):

 Starting Pay:
 Final Pay:
Name of Immediate Supervisor:
 Supervisor’s Title:
May We Contact:
Yes No If No, Why?
Reason for Leaving:
Name of Current or Last Place of Employment:
 Telephone Number:
Street Address:
City:
 State:
Zip Code:
Job Title:
 Explain Job Duties:
Date Started (M-D-Y):
 Date Left (M-D-Y):

 Starting Pay:
 Final Pay:
Name of Immediate Supervisor:
 Supervisor’s Title:
May We Contact:
Yes No If No, Why?
Reason for Leaving:
Name of Current or Last Place of Employment:
 Telephone Number:
Street Address:
City:
 State:
Zip Code:
Job Title:
 Explain Job Duties:
Date Started (M-D-Y):
 Date Left (M-D-Y):

 Starting Pay:
 Final Pay:
Name of Immediate Supervisor:
 Supervisor’s Title:
May We Contact:
Yes No If No, Why?
Reason for Leaving:
Have you ever been involuntarily dismissed, terminated or forced to resign from any employment?*
Yes
No
If “yes”, please explain:

Military Experience:

Have you ever served in the U.S Armed Forces? Yes
 No
Describe any job-related training you received while in the Service:
 From:
 To:

General Information:

What prompted your application? Please indicate source or sources) *

Other Description:*

  

Are you under 18 years of age? * Yes
 No
Have you ever worked for Private Home Care, Home Staff, Inc. or Pri-Med Infusion Services before? * Yes
 No
If “yes”, please provides dates of employment and position held:
If offered a position, can you provide genuine documents to verify your identify and employment eligibility within the United States? * Yes
 No
Are you currently listed as debarred, excluded from or otherwise ineligible from participation in federal health care programs such as
 Medicare defined in 42-USC 1320a-7b(f)?		 Yes
 No
Have you been debarred, excluded from or otherwise determined to be ineligible from participation in federal health care programs
 within the last 10 years? 		Yes
 No
Have you ever been convicted of a crime or violation other than a minor traffic infraction? *

 When answering this question, do not include convictions that have been expunged or sealed.
 A criminal record is not necessarily a bar to employment.

 Yes
 No
If “yes”, please explain:
Note: Private Home Care, Pri-Med Infusion Services and Home Staff, Inc. conduct background checks on candidates offered employment as one of the conditions of employment.

References:

Note: Please list professional references who have directly supervised you in the work environment. Do not list relatives or personal friends.
Name: Company: Title: Years
Acquainted:		 Phone Number:

 

Please Read Carefully Before Signing


I hereby affirm that the information provided in this application and accompanying resume (if any) is true to the best of my knowledge and that any falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal or withdrawal of an offer of employment if discovered at a later date.

I authorize investigation and verification of all statements contained within this application including but not limited to: education, licensing, background checks, references as it pertains to employment and standard practices of the companies.  I agree to such reference and background checks and release from liability of all persons and corporations requesting and providing such information.

I understand that the offer of employment, if extended, is contingent upon providing documentation that establishes both my identity and my authorization to work in the United States, successful and positive references and background checks.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Private Home Care, Pri-Med Infusion, Home Staff, Inc. and myself. No promises regarding employment or duration of employment have been made to me. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and Private Home Care, Pri-Med Infusion, Home Staff, Inc. retains a similar right, with or without cause.

My typed name below shall have the same force and effect as my written signature.

Signature:         Date: