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Home Health Care Resource – Professional home health, dementia, alzheimers, care provider resource to help people make the best choice for your loved ones.

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Click Here to Download a Printable Copy of the Application Below.

Or Submit the Online Form Below:

Full name:
Present Address:
City, State, Zip:   
Home Phone:
Cell Phone:
E-mail address:
Permanent Address:
(If different from above)
City, State, Zip:   
Best way to contact you:

EDUCATION

Education Level Name and Location of School City/State (List Campus Attended) Diploma/Degree Major Area of Study
High School
Vocational/Trade/Technical School
Professional or Diploma
College/University
(undergraduate)
College/University
(graduate)
Other

LICENSES

List any pertinent licenses held to include CPR/Certification, RN and CNA license number, expiration date.

License/Certification State/License No. Date/Year Issued Expiration Date Temporary Permanent
   
   
   
   

WORK HISTORY

Include paid or verifiable non-paid experience, including military service. If you have had more than one position with the same employer, please list each separately. It will help us process your application more quickly through our background verification check if you provide complete and accurate addresses of former employers.

1. Most Recent Employer
Company Name: Job Duties and Responsibilities:

Reason for Leaving:

May we contact this employer for a reference?

 Yes No
Street Address:
City, State, Zip:   
Employer's Phone:
Other Name(s) Used:
Job Title:
Dates Employed: From: To:
Starting Salary:
Ending Salary:
Supervisor's Name:
Employment Status:  Full-Time Part-Time PRN
2.
Company Name: Job Duties and Responsibilities:

Reason for Leaving:

May we contact this employer for a reference?

 Yes No
Street Address:
City, State, Zip:   
Employer's Phone:
Other Name(s) Used:
Job Title:
Dates Employed: From: To:
Starting Salary:
Ending Salary:
Supervisor's Name:
Employment Status:  Full-Time Part-Time PRN
3.
Company Name: Job Duties and Responsibilities:

Reason for Leaving:

May we contact this employer for a reference?

 Yes No
Street Address:
City, State, Zip:   
Employer's Phone:
Other Name(s) Used:
Job Title:
Dates Employed: From: To:
Starting Salary:
Ending Salary:
Supervisor's Name:
Employment Status:  Full-Time Part-Time PRN
4.
Company Name: Job Duties and Responsibilities:

Reason for Leaving:

May we contact this employer for a reference?

 Yes No
Street Address:
City, State, Zip:   
Employer's Phone:
Other Name(s) Used:
Job Title:
Dates Employed: From: To:
Starting Salary:
Ending Salary:
Supervisor's Name:
Employment Status:  Full-Time Part-Time PRN

MILITARY SERVICE

Branch of Service:
Period of Duty:
Rank:
Status:

RESUME

Resume:
Cutting and Pasting your Resume:
1. Highlight the text on the resume you want to copy.
2. Press 'Ctrl C' to copy (Hold down the Ctrl Key and press C)
3. Place the cursor in the RESUME box below.
4. Press 'Ctrl V' to paste the information

Cover Letter
Resume

REFERENCES
Please provide three professional references (DO NOT list relatives)

Name Phone Number Address Relationship

ADDITIONAL INFORMATION

When will you be available to work?
How did you find out about this position?

Please answer the following questions:

 Yes No Have you ever been convicted of a felony?
If yes, please explain the nature of the offense, date and location in the space provided below.
 Yes No If employed, can you submit proof that you are at least 18 years of age?
 Yes No Are you legally entitled to work in the U.S.A.?
After employment, can you provide proof of Citizenship, Visa, or Alien Registration?
 Yes No Have you ever worked for Health Exchange of Arizona?
If Yes, list dates and locations Positions Held:
 Yes No Do you have any responsibilities or commitments that may prevent you from meeting work and attendance requirements?
 Yes No Do you have any friends or relatives employed by HEOA?
If Yes, list Names Location:

Additional information about yourself which will aid in evaluating your career interests and abilities?

PLEASE READ AND SIGN

In completing an application for employment with Home Health Exchange, I understand and acknowledge the following:

1. The information given by me on this application is true in all respects and I have not failed to disclose information which HHE could consider relevant to the hiring decision. I understand that I may be refused employment or, if employed, terminated should misrepresentations be discovered.

2. I voluntarily give HHE the right to make a thorough investigation of my past employment activities, agree to cooperate in such investigations and authorize all persons, and companies to supply such information to HHE. I consent to take the pre-employment physical examination, if offered employment and such future examinations as may be required by HHE at such times and places HHE shall designate.

3. I understand that HHE reserves the right to test for drug use of any applicant or employee at any time.

4. I understand that if employed, my employment is for no definite period of time and is "at will" and no other than the HHE President has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to these terms and only if in writing.

5. Should I become employed with HHE, I agree to conform to its rules and regulations and any modifications or amendments thereto including but not limited to its code of conduct. Also, I will preserve the strictest confidence of all information concerning the business of HHE and patients.

My typed name below shall have the same
force and effect as my written signature.
Candidate's / Applicant's Signature:
Date: