Application for Employment - New Path Quality

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Application for Employment

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About New Path Quality
Application for Employment

New Path Quality Home Healthcare is an equal opportunity employer. All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.

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Today's Date: *

Name: *

First

Middle

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth: *

Social Security Number: *

Cell Phone: *

Home Phone: *

Email: *

Emergency Contact Name and Number:

Have you ever applied with this agency? *

Yes
No

How many hours a week are you available for work? *

Are you legally eligible for employment in the United States? *

Yes
No

Has your last name changed in the last five (5) years? *

Yes
No

If yes, what was your last name? *

Are you currently employed? *

Yes
No

Do you have reliable transportation? *

Yes
No

How did you learn of our organization?

Newspaper Ad
Agency Employee
Social Media
Other

If other

Are you willing to work: *

Evenings
Weekends
Both

Position applying for: *

LVN
RN
Therapist
Other

If other (copy)

High School Education:

High School Name: *

Location (City, State): *

Year Graduated: *

Diploma Earned: *

College or University Education:

College or University Name: *

Location (City, State): *

Year Graduation: *

Degree Earned: *

Vocational School/Specialized Training:

Vocational School or Specialized Training Name: *

Location (City, State): *

Year Graduated: *

Degree Earned: *

Previous Employer 1:

List the last five (5) years employment history, starting with the most recent employer.

Employer Name: *

Supervisor Name: *

Employer Address *

Employer Telephone: *

Start Date: *

End Date: *

Reason for Leaving: *

Previous Employer 2:

Employer Name: *

Supervisor Name: *

Employer Address: *

Employer Telephone: *

Start Date: *

End Date: *

Reason for Leaving: *

Previous Employer 3:

Employer Name: *

Supervisor Name: *

Employer Address: *

Employer Telephone: *

Start Date: *

End Date: *

Reason for Leaving: *

Previous Employer 4:

Employer Name: *

Supervisor Name: *

Employer Address: *

Employer Telephone: *

Start Date: *

End Date: *

Reason for Leaving: *

Previous Employer 5:

Employer Name: *

Supervisor Name: *

Employer Address: *

Employer Telephone: *

Start Date: *

End Date: *

Reason for Leaving: *

Professional References

List three (3) personal references who can furnish information about your job performance.

Name *

Telephone *

Address *

Relationship: *

Years Known: *

Professional Reference 2:

Name: *

Telephone *

Address: *

Relationship: *

Years Known: *

Professional Reference 3:

Name: *

Telephone: *

Address: *

Relationship: *

Years Known: *

General Information

Have you ever been convicted of a crime in the past five (5) yers, barring employment in a Home Care and community support agency (conviction will not necessarily disqualify an applicant from employment)? *

Yes
No

If yes, describe in full: *

Are you capable of performing the job set forth in the job description?

Yes
No

If no, which job requirement can you not meet? *

Credentials/Specialized Skills & Qualifications/Equipment Operated *

List all states in which licensed, giving registration and expiration date. Summarize special jobrelated skills and qualifications acquired from employment and/or other experience.

Upload your resume *

Click or drag a file to this area to upload.

File Upload

Click or drag a file to this area to upload.

Additional Information

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DISCLAIMER AND SIGNATURE:
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE
GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background history with all persons
and entities listed above to give the Agency any and all former employees and others listed above
from all liability for any damage that may result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may,
regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not exceeding
forty-five (45) days. Any applicant wishing to be considered for employment beyond this time
period shall inquire as to whether or not applications are being accepted at this time.

Signature:

Todays Date:

Contact Number

918-933-7800

Our custom care and treatment plans are thoroughly tailored for the purpose of keeping your loved one comfortable in their own home and environment. We hold their health and independence to high regard and help them navigate their new normal.

[email protected]
http://newpathquality.com
8310 E. 73rd St. Ste. 105 Tulsa, OK 74133

Our Services

Skilled Nursing
Companion Care
Transitional Care
Speech Therapy
Physical Therapy
Occupational Rehab

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