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This agency is an equal opportunity employer. Federal and State laws prohibit discrimination in employment practices because of race, color, religion, age, sex, national origin or non job-related hanicap or disability. No question on this application is asked for the purpose of excluding any applicant from consideration for employment because of his or her race, color, religion, age, sex, national origin or non job-related handicap or disability.

Please complete this form and click on the send button at the bottom. Any information you provide to us will be kept confidential - meaning we will not resell, share, lend or give any of the following information you provide to us to any organization or person outside of our company.


*Required Fields

referral source: ad employee
school other
status desired: full time
part time
weekends
day shift
evening shift
night shift
DATE OF BIRTH: NAME:
ADDRESS: City:
    Zip Code: PHONE #:
email address:    

1.
last
job
employer: supervisor:
Phone: ending salary: / HR
Employed from: to   full time   part time
reason for
leaving:
    explain duties and responsibilities:

2.
next to
last job
employer: supervisor:
Phone: ending
salary:
/ HR
Employed from: to   full time   part time
reason for
leaving:
    explain duties and responsibilities:

3.
job
before
above

employer: supervisor:
Phone: ending
salary:
/ HR
Employed from: to   full time   part time
reason for
leaving:
    explain duties and responsibilities:

may we contact your present employer?: yes         no
have you ever applied for or received benefits for workmen's compensation or disability?: yes         no
have you ever been sued or submitted a claim for professional liability?: yes         no
If yes, please explain:
have you ever been convicted of a crime other than a misdemeanor or summary offensive?: yes         no
if yes, please explain:
U.s. citizen? yes         no            may we do a criminal background check? yes         no

education name from mo/yr to mo/yr yr graduated major subject degree
high school
nursing / college
vocational / bus.

personal references: other than former employers or relatives
name occupation address & phone yrs known

person to be notified in case of accident or emergency:
name phone relationship

I hereby authorize Rx Home Health Services, Inc. and also authorize and request each former employer, person or corporation given as a reference, to give all information as it may be sought in connection with the application or concerning me, my work habits, character, skill or my action in any transaction. I agree in consideration of your employing me, that I will not seek or accept employment either directly or indirectly from any client of Rx Home Health Services, Inc., to whom I have been assigned, for at least 120 days after the last date of that assignment. I certify that the information herein is true and correct to the best of my knowledge and belief.

Thank You!

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RX Home Care, Inc.
207 West Broad St.
Bethlehem, PA 18018
phone: 610-868-1801