Live Free Home Health Care, LLC. - Bristol, New Hampshire

Contact Information

First Name*:

Home Phone*:

Email*:

Address*:

State*:

Last Name*:

Cell Phone:

City*:

Zip Code*:

Are you authorized to work in the US?*

Are you 18 years of age or older?*

Date of Birth*:

What position are you applying for?

RN   LPN   LNA   Caregiver
Other:

Yes   No

Yes   No

If you are hired, when can you start?

Desired rate of pay her hour?

Certifications (Check one or more)

RN   LPN   LNA

License Number:

License Expiration Date:

Education

High School
Name of school:

Number of years attended:

Date of graduation:

Location:

Did you graduate?
Yes   No

College
Name of school:

Number of years attended:

Date of graduation:

Location:

Did you graduate?
Yes   No

What degree did you earn?

Other School
Name of school:

Number of years attended:

Date of graduation:

Location:

Did you graduate?
Yes   No

What degree did you earn?

Employment History

Beginning with your most recent employment and working back in time, please give the following information:

Employer 1
Employer:

Address:

Phone Number:

Job Title:

Salary/Hourly Rate:

Duties:

Dates of Employment:

Supervisor:

Reason for Leaving:

Employer 2
Employer:

Address:

Phone Number:

Job Title:

Salary/Hourly Rate:

Duties:

Dates of Employment:

Supervisor:

Reason for Leaving:

Employer 3
Employer:

Address:

Phone Number:

Job Title:

Salary/Hourly Rate:

Duties:

Dates of Employment:

Supervisor:

Reason for Leaving:

Personal References

Please provide the names of two references who have not employed you and are not related to you.

Reference 1
Name:

Address:

Phone Number:

Relationship:

Reference 2
Name:

Address:

Phone Number

Relationship:

Preferences

Will you travel 30 minutes?
Yes   No

Will you work every other weekend?
Yes   No

Will you work short shifts?
Yes   No

Will you work long shifts?
Yes   No

Have you ever had home health experience?
Yes   No

How many hours per week are you willing to work/What is your ideal number of hours to work?

What is a minimum number of hours per week for you to accept a position?

What is a maximum number of hours per week for you to work?

Please indicate your availability:

In which of the following areas have you had experience?

Job Description

Any caregiver with our agency should be aware that home health care involves direct client care, may involve lifting and transferring clients, exposure to household pets and fluctuations in hours based on our clients’ needs.

Do you have any concerns or limitations in this regard? Yes   No

If yes, please explain:

Additional Qualifications

Please tell us about any other special training in nursing, education, skills or achievements that you feel should be considered.

Have you ever been convicted of abuse, neglect, or exploitation? Yes   No

Do you have an offense that will show on your criminal record? Yes   No

If yes, please explain when this was and what the violation was:

Agreement and Submission

I certify that this information is correct and acknowledge that its accuracy is subject to verification by Live Free Home Health Care, LLC. I understand that furnishing incorrect information will render this application void and will be just cause for termination.

Applicant's Signature*:

Date*:

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