Employment Form

Last Name *

First Name *

Middle Initial or Maiden

DOB:

SS#:

Primary Contact:

Secondary Contact:

Other Name(s) by which you have been known (for date verification and reference checking purposes)

Driver's License Number

State

Street Address

City

State

Zip Code

Mailing Address (if different from Above)

City

State

Zip Code

Would you upon hire be able to provide the necessary documents of proof of the legal right to work in the U.S.?

Yes

No

Are you under the age of 18?

Yes

No

Have you ever worked for Accessible Healthcare Solutions?

Yes

No

Have you ever plead guilty or no contest to, or been convicted of any crime?

Yes

No

If YES, give date, place, offense, and outcome.

It is a crime in itself to fail to provide accurate information in response to this question. (Previous convictions do not necessarily disqualify an applicant from employment.)

Are you a CNA

Yes

No

CNA#

Military Service

Yes

No

Branch of Service

Position Desired

Salary Desired

Date Available

Shifts you can work

Day

Evening

Night

Weekend

Circle Highest grade/level successfully completed:

High School

9th

10th

11th

12th

Technical College (years)

1

2

3

Name of High School, Technical School and College

City and State

Major

Degree (if any)

Month/Year Graduated

Please list at least one present or former manager-DO NOT include relatives

Name

Address

Phone

Relationship

Tell me about yourself

List all relatives currently working at AHS (for job assignment considerations only)

Do you have relatives who receive services from AHS? (current or former clients)

Tell us about your favorite job and why you liked it. (If you have not worked in the past, tell us your favorite high school or college class and why you liked it.)

What about your least favorite job? What made it not so good? (If you have not worked in the past, tell us about your least favorite high school or college class and why you did not like it very much.)

To strive to improve the quality of life for people with disabilities in our local community, by means of state endorsed programs and developmental initiatives assisting them to reach their full potential.

Accessible HealthCare Solutions, LLC has a policy of equal employment opportunity, requiring that certain information be gathered and documented for statistical purposes only. To assist us in maintaining accurate employment records and compile record, your assistance is requested. The information you provide (below) is considered entirely voluntary and confidential, and will be used only for data reporting requirements. If you choose not to self-identify, your employment status will not be affected in any way.

Accessible HealthCare Solutions, LLC is an Equal Employment Opportunity employer. We conduct all employment-related activities without regard to race, color, sex, religion, age, origin, disability, veteran status, sexual orientation or any other classification protected by applicable State or Federal employment discrimination laws. Accessible welcomes diversity in the workplace.

Please check the categories which apply to you.

Gender

Male

Female

Black (African American) not of Hispanic Origin: All persons having origins in any of the Black racial groups of Africa

Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, Samoa, and India.

Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin.

White, not of Hispanic Origin: All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

Vietnam Era Veteran: (a) Persons serving more than 180 days of active military, navy, or air service regardless of where the person was posted geographically, any part of which was during the period of August 5, 1964, through May 7, 1975, and who (1) was discharged or released with other that a dishonorable discharge, or (2) was discharged or released from active duty because of a service-connected disability, if any part was between August 5, 1964 , and May 7, 1975, or (b) Persons who served more than 180 days of active military, navy, or air service within the Republic of Vietnam, any part of which was during the period of February 28, 1961, through May 7, 1975, and who (1) was discharged or released with other than dishonorable discharge, or (2) was discharged or released from active duty because of a service-connected disability, if any part was between February 28,1961 and May 7, 1975.

Print Name *

Signature: *

Date

Position Applied for:

I (please print full name) certify the information contained below is correct to the best of my knowledge, and I understand that any misstatement or omission of information is grounds for ending the application process.

In compliance with Louisiana Law R.S. 12: 126.3, you must list any past or current employment in any nursing home, mental retardation/mental health facility, hospital, home health agency, hospice or other residential facility required to be licensed and operated by the laws of this state. We are required to report all violations to the Louisiana Department of Justice.

Company Name

City

State

Phone #

Job Title

Supervisors Name

From

To

Job Duties

Reason for Leaving

Company Name

City

State

Phone #

Job Title

Supervisors Name

From

To

Job Duties

Reason for Leaving

Company Name

City

State

Phone #

Job Title

Supervisors Name

From

To

Job Duties

Reason for Leaving

Company Name

City

State

Phone #

Job Title

Supervisors Name

From

To

Job Duties

Reason for Leaving

Company Name

City

State

Phone #

Job Title

Supervisors Name

From

To

Job Duties

Reason for Leaving

Company Name

City

State

Phone #

Job Title

Supervisors Name

From

To

Job Duties

Reason for Leaving

Please notify Human Resources staff if additional paper is needed for additional employment history.

I authorize verification of information provided; and authorize the references listed above to give you all pertinent information concerning my previous employment, and release all parties from all liability for any damage that may result from furnishing same to Accessible Healthcare Solutions. In consideration of my employment, I agree to confirm to the rules and regulations of Accessible Healthcare Solutions, LLC. I further agree that either I or the Company may terminate my employment with or without cause and with or without prior notice, at any time. Finally I understand that no representative of the Company other than the Executive Director has the authority to enter into my agreement for employment for any specified period of time, or to alter the foregoing.

Signature: *

Date

An offer of employment at Accessible Healthcare Solutions, is contingent upon:

An acceptable drug screen
An employment background acceptable to state and federal standards of Department of Health and Hospitals
A criminal background that included no convictions which are preluded by the standards of Department of Health and Hospitals
Satisfactory interview
Successful completion of on-line training and in-class orientation I also understand that an offer of employment by Accessible Healthcare Solutions constitutes no contractual relationship, nor does it alter the Company's status as an "At Will Employer"

If offered employment by AHS I would like to be considered for the following position(s):

Job Title(s):

I am available to work the following shift(s):

Morning

Evening

Night

Part-time (indicate amount of hours available, weekly and/or monthly):

PRN (indicate amount of hours available, weekly and/or monthly):

Signature: *

Date

Name:

Relationship:

Phone

Address

City:

State:

Zip

Name:

Relationship:

Phone

Address

City:

State:

Zip