First Name *

Last Name *

Middle Initial *

Date of birth *

Phone *

Street Address *

City *

State *

Postal code *

Any Other Name by Which Known *

Birth Date *

Position(s) Applying For? *

Email *

Can you upon hire provide proof of your Legal right to work in the United States? *

Yes

Have you ever been convicted of a crime? *

Yes

If yes, please explain

Expected Salary or Hourly Pay *

Date Available To Start Work *

Type of Employment Desired *

Full Time

Part Time

Temporary

Preferred Shifts *

Weekdays

Weekends

Available Time

From *

To *

Have you ever been previously employed by Vital Sign Home Care, INC? *

Yes

Do You Have any Relatives That Work For Vital Sign Home Care, INC ? *

Yes

Do you have any physical condition which may limit your ability to perform the job for which you are applying? *

Yes

Name and Location of School:

High School or G.E.D. *

Did you graduate? *

Yes

College

Did you graduate?

Yes

Degree

Additional Education, Training, Professional Activities or Accomplishments, Skills, or Certificates *

How were you referred to Vital Sign Home Care? *

Please give us the NAMES, and BUSINESS TELEPHONE NUMBERS of people who are familiar with your WORK EXPERIENCE and TECHNICAL COMPETENCE in the job for which you are applying, preferably technical associates with whom you have worked and give Vital Sign Home Care permission to contact. (DO NOT LIST PERSONAL REFERENCES.)

Reference #1: Name *

Reference #1: Business/Professional Relationship *

Reference #1: Company *

Reference #1: Title *

Reference #1: Business Phone *

Reference #2: Name *

Reference #2: Business/Professional Relationship *

Reference #2: Company *

Reference #2: Title *

Reference #2: Business Phone *

Most Recent Employer

May We Contact *

Yes

If “NO” explain why?

Dates Employed

From: *

To: *

Supervisor’s Name *

Telephone (work) *

Street Address *

City *

State *

Zip Code *

Position(s) Held *

Reason for Leaving *

Describe Major Work Duties *

Second Most Recent Employer

May We Contact *

Yes

If “NO” explain why? *

Dates Employed

From: *

To: *

Supervisor’s Name *

Telephone (work) *

Street Address *

City *

State *

Zip Code *

Position(s) Held *

Reason for Leaving *

Describe Major Work Duties *

Tell Us About Your Level of Experience with the Following:

Experience working with Psych Patients? *

Experience Working with Dementia Patients? *

Experience Working with Hospice Patients? *

Experience Working with a Hoyer Lift? *

Experience Working with Private Duty Clients? *

Experience Working with Developmentally Disabled Clients? *

For Professional or Managerial positions, complete the following: (Includes all caregivers) *

I am subject to an employment agreement or other non-compete agreement which would impact my accepting employment with Vital Sign Home Care

I am not subject to an employment agreement or other non-compete agreement which would impact my accepting employment with Vital Sign Home Care

General

Incontinence Experience *

Okay for smoking *

Do you have an insured automobile? *

Is a live-in shift okay? *

Can you transfer a patient from a wheelchair to a vehicle? *

What is your weight limit? *

Transfer

Gait and Belt Experience *

Pets

Okay with Dogs *

Okay with Cats *

Additional Information

Can you transfer a patient from a wheelchair to a vehicle or bed? *

Do you have any medical conditions that would prevent you from heavy lifting? *

How do you handle people who are angry, stubborn, or fearful? *

Give an example of a difficult situation you handled with a client. For instance, how did you handle refusing to take a shower? *

What are your dreams and aspirations? Include both professional and personal goals, please explain *

Certification/Background Check/Drug Test Consent: *

Consent Screening/Background Check/Drug Test * By checking this box you give consent to Vital Sign Home Care, LLC to perform a national background check and drug test.

All employees must upload an unexpired State ID or Driver’s License.

Attach Documents *

Upload Files

Read and Electronically Sign Below:

I hereby give Vital Sign Home Care the right to make a thorough investigation of my past employment, education and activities and release from all liability whatsoever al persons, companies, and corporations supplying such information.

I expressly agree to indemnify Vital Sign Home Care against any liability, which might result from making such investigation.

I understand that any false answers, statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Vital Sign Home Care, and myself for either employment or for the providing of any benefit.

No promises regarding employment have been made to me and I understand that no such promise or guarantee is binding upon Vital Sign Home Care unless made in writing.

If an employment relationship is established, I understand that I have the right to terminate my employment at any time for any reasons, and that Vital Sign Home Care retains a similar right.

I have no objection to making application for security clearance, if necessary, signing an employee agreement on confidential information and inventions, or taking a medical examination.

I also agree to provide, if necessary, the results of a physical examination completed no more than six months ago, at no cost to Vital Sign Home Care.

I also authorize Vital Sign Home Care to release such medical information as may be necessary to their clients for obtaining approval of my assignment to a client's facility or home.

I understand and agree that I may be required to take a skills assessment examination.

My signature below is an acknowledgement that I have fully read, understand and agree with all terms and conditions of this application.

Date *

By filling in your name below, this serves as your electronic signature.

Applicant Name *