Application Date

Full Name

Address

Telephone Number

Cellular Number

arrow&v

Social Security Number

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis?

(You may be required to provide documentation.)

Are you over 18 years of age?

Employment Desired

Position Applied for

Date you can start?

Select desired shift(s):

Please list hours of availability each day:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Wellness Alliances is and equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicant requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

How did you learn of this opening?

Are you over 18 years of age?

Have you ever applied with A Gentle Touch Home Care?

Previously worked for A Gentle Touch Home Care?

When?

Supervisor

Reason for leaving:

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

If no, describe the functions that cannot be performed:

Note: Company complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that the new hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.

What are your means of transportation? Check the all that apply.

Bus

Self-owned car

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?

Do you speak, write, or understand any foreign languages?

If yes, describe which language(s) and how fluent of a speaker you consider yourself to be?

Criminal History Statement

Have you ever been convicted of a felony?

Have you ever been convicted of a misdemeanor?

If yes, please explain:

INFORMATION TO THE APPLICANT

As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by it's terms. I understand and agree to the information shown above.

Your Name

Date

Education

High School

Name

Address

Diploma/

GED Earned

College/University

Name

Address

Course of Study

Certificate(s) Earned

Graduate School

Name

Address

Course of Study

Certificate(s) Earned

Trade/Vocational

Name

Address

Course of Study

Certificate(s) Earned

Employment History

PLEASE FOLLOW THESE INSTRUCTIONS: Please give the details of your previous jobs.  Applicant must provide all information requested including complete address, city, state, zip code, telephone number and if possible, fax number. Application will not be processed it not completed accurately.

Employer

Position

From

To

Address

Telephone Number

Name of Supervisor

Starting Wage

Ending Wage

May we contact?

Responsibilities

Reason for leaving

arrow&v

Employer

Position

From

To

Address

Telephone Number

Name of Supervisor

Starting Wage

Ending Wage

May we contact?

Responsibilities

Reason for leaving

What skills do you have that would be useful in this line of work?

Tell us about yourself:

arrow&v

Personal References

PLEASE FOLLOW THESE INSTRUCTIONSExcluding relatives and former employers, list three references. You must provide all information requested including complete address, city, state, zip code, and telephone number. Application will not be processed if not completed accurately.

Name

Address

Phone Number

Years Acquainted

Relationship

arrow&v

Name

Address

Phone Number

Years Acquainted

Relationship

arrow&v

Name

Address

Phone Number

Years Acquainted

Relationship

arrow&v

Emergency Contact Information

Name

Phone Number

Relationship

Preferences

Preferences

Cats (would you consider taking care of clients that own cats?)

Dogs (would you consider taking care of clients that own dogs?)

Housekeeping (would you accommodate cleaning the client's house?)

Patient Care (would you be able to accommodate patient care? Examples: bathing, grooming and meal preparation?)

Companionship (would you want to work for a client who only requires companionship?)

Las Vegas

Your Home District

Anthem

N. Las Vegas

Summerlin

Henderson

Your Major Cross Streets

DISTRICTS (Areas where the applicant can accommodate to service clients)

Southeast

Southwest

Northeast

Northwest

Henderson

Employment Agreement

This agency does not discriminate in hiring based on race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, age, physical, or mental disability. No information requested on this application is intended to secure information to be used for such discrimination.

I voluntarily give this agency the right to make a thorough investigation of my past employment and activities. I also agree to cooperate in such investigation and release from liability or responsibility all persons companies or corporations supplying such information. I understand that my employment may be contingent on the completion of the pre-employment requirements (Live Scan, HCA Registration and Clearance, current CPR card, TB Test/Chest X-ray (completed within last 90 days, auto insurance, valid proof of identification, DMV Report, Human Resource Orientation and Safety Training) as these relate to the essential duties that I would be required to perform.

I understand that my employment is at will; either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to present satisfactory evidence of identity and eligibility of employment and complete an Employment Verification Form (I-9).

Your Name

Date

Task & Skills Inventory

Please indicate your level of experience in the following areas by checking the box:

Please indicate if you have any of following Certifications:

LVN/LPN/RN

CNA

MA

Call us today on 1-702-815-9012

© 2018 by Wellness Alliances.