Apply Today - Assure Home Healthcare Inc.

Personal Information
Date of Application:*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Are you 18 years of age or older:*
- Yes
- No
If hired, can you provide written evidence that you are authorized to work in the U.S.?*
- Yes
- No
Phone*
Best number to reach you

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Job Specifications
Position Desired:*
Salary Expectation:
Applying for:
Willing to and available for work on:
I will be able to start work:
- Any Time
- After Two Weeks Notice
Starting on:

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Source of Information
I came to know about the job opening and the company through:*
- Facebook
- Linkedin
- Tweeter
- Indeed
- * Assure Employee
If you choose *Assure Employee, please mention who referred you.

Assure's Employee Name

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Level of Education
High School*
- Yes
- No
High School: Name/Location/Year*
Technical or Other Training*
- Yes
- No
Technical or Other Training: Name/Location/Year*
College or University*
- Yes
- No
College or University: Name/Location/Year*
Post-Graduate*
- Yes
- No
Post-Graduate: Name/Location/Year*

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Employment History 1
Employer 1:*
Period, from and to (Month and Year)*
Month Year
Employer Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor Name:
Supervisor Phone:
Career Status
Title:
Employment Status
- Full Time
- Part Time
- Contractual/Consultante
Duties and Responsibilities:
Reason(s) for leaving:

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Employment History 2
Employer 2:
Period, from and to (Month and Year)
Month Year
Employer Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor Name:
Supervisor Phone:
Career Status
Title:
Employment Status
- Full Time
- Part Time
- Contractual/Consultante
Duties and Reponsabilities:
Reason(s) for leaving:

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Employment History 3
Employer 3:
Period, from and to (Month and Year)*
Month Year
Employer Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor Name:
Supervisor Phone:
Career Status
Title:
Employment Status
- Full Time
- Part Time
- Contractual/Consultante
Duties and Reponsabilities:
Reason(s) for leaving:

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Conviction/Work Record
Do you have any relative working for ASSURE Home Healthcare, Inc.:*
- Yes
- No
If YES, please, specify the employee’s name:
Is there any information we would need about your name, or use of another name, for us to be able to check your work record?
- Yes
- No
If YES, please specify:

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Professional Licenses, Registration/Certification
Type / Discipline:*
Nurses please add your professional licenses, registration and certification. Others please add N/A (Not Available).
Issued in what state, by what agency and when?*
Number*
Expiration Date:*
Month
Day
Year
Computer Background/Skills:
Please Specify:

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U.S. Military Service
Branch of Service:
Length:
From To
Rank/Type of Service:
Location:
Training Received/Experience Gained:

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Note:

The applicant is required to attached to this application form an updated Resume.

APPLICANT’S STATEMENT:

I understand that any false statements or material omissions made as a part of this application will disqualify me from further consideration for employment, and if discovered later, will be grounds for discharge.

I also understand that any offer of employment is contingent upon the results of a pre-employment medical examination, drug screen, criminal background and reference checks.

I hereby authorize my former employers to release all information during or after my employment, without prior notification.

This authorization releases the aforesaid parties and ASSURE Home Healthcare, Inc. from any liability for the collection and reporting of this information.

ASSURE Home Healthcare, Inc. does not discriminate in hiring or employment on the basis of sex, color, marital status, religion, sexual orientation, national origin, age, disability, military status, or any other protected category.

No question on this application is intended to secure information to be used for such discrimination.

I understand that if I am hired by ASSURE Home Healthcare, Inc. , my employment is “at will” and thus, may be terminated by me or by the employer at any time with or without cause, for any reason. No one other than the President of the agency has the authority to enter into an agreement contrary to the foregoing, and any such agreement must be in writing and signed by both the President and me.

Finally, I will willingly submit all documents as required for hiring or employment.
I'm hereby authorize Assure Home Healthcare Inc. to investigate my background and qualifications for purposes of evaluating whether I am qualified for the position for which I am applying. I understand that Assure Home Healthcare, Inc. will utilize an outside firm or firms to assist it in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.*
- Yes
- No
Please upload your resume:
Accepted file types: jpg, gif, png, pdf, txt, doc, rtf, ppt, Max. file size: 512 MB.
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Step 1 of 11 - Personal Information

Personal Information

Job Specifications

Source of Information

Level of Education

Employment History 1

Employment History 2

Employment History 3

Conviction/Work Record

Professional Licenses, Registration/Certification

U.S. Military Service

Note:

APPLICANT’S STATEMENT:

Month	Year

Title:

Month	Year

Title: