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Application Form Available Here

Application Form for Direct Support Professionals and Nurses

Today’s Date(Required)

Personal Data

Email Address(Required)

Name(Required)

First Middle Last

Address(Required)

Home Address City State ZIP Code

Home Phone

Cell Phone(Required)

Pager

Emergency Contact Information

Name of Emergency Contact(Required)

Relation

Emergency Telephone Number(Required)

Job Information

Position (Job Class) Applying for:(Required)

Date Available(Required)

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Previous Facility Types Worked: Check All That Apply –(Required)

Hospital

Hospice

Nursing Home

Rehab

Private Duty

Assisted Living / Residential Treatment

Language Skills: Other than English, please check any other languages you speak –(Required)

Spanish

French

German

Other:

Check the type of assignment you are available for:(Required)

Full-time

Part-time

Contract

Travel

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Check the days of the week you are available to work:(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Holidays available to work:

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List(Required)

License Type

License/Certification#

State

Expiration Date

List

License Type

License/Certification#

State

Expiration Date

List

License Type

License/Certification#

State

Expiration Date

Has your professional license ever been suspended, revoked or under investigation?(Required)

YES

If Yes, Please explain:

Certifications: Check all applicable certifications and enter expiration date:(Required)

ACLS

BCLS

CPR

PALS

Other

NALS

ACLS Expiration Date:

BCLS Expiration Date:

CPR Expiration Date:

PALS Expiration Date:

Other Expiration Date:

IV Expiration Date:

NALS Expiration Date:

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Facility/Employer Name(Required)

Date Employed

From(Required)

To(Required)

Address(Required)

City State ZIP Code

Title(Required)

Name of Current Immediate Supervisor(Required)

Describe duties and specialty areas:(Required)

Telephone #:(Required)

Pay Rate/Salary:

Hourly(Required)

Yearly(Required)

May We Contact:(Required)

Yes

No – If no, why?

Reason for leaving:(Required)

Reason for leaving: If this was a travel assignment, name of agency:

Are your employment records listed under another name?(Required)

Yes

Yes – If yes, why?

Supervisory Experience:(Required)

Yes

No – How often?

Facility/Employer Name

Date Employed

From

Address

City State ZIP Code

Title

Name of Current Immediate Supervisor

Describe duties and specialty areas:

Telephone #:

Pay Rate/Salary:

Hourly

Yearly

May We Contact:

Yes

No – If no, why?

Reason for leaving:

Reason for leaving: If this was a travel assignment, name of agency:

Are your employment records listed under another name?

Yes

Yes – If yes, why?

Supervisory Experience:

Yes

No – How often?

Facility/Employer Name

Date Employed

From

Address

City State ZIP Code

Title

Units

Number of Beds in Unit:

In Hospital:

Name of Current Immediate Supervisor

Describe duties and specialty areas:

Telephone #:

Pay Rate/Salary:

Hourly

Yearly

May We Contact:

Yes

No – If no, why?

Reason for leaving:

Reason for leaving: If this was a travel assignment, name of agency:

Are your employment records listed under another name?

Yes

Yes – If yes, why?

Supervisory Experience:

Yes

No – How often?

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.

Additional Information:

Are you legally authorized to work in the USA?(Required)

Yes

Have you ever been convicted of a felony?(Required)

Yes

Can you pass a pre-employment drug test?(Required)

Yes

How were you referred Over The Moon Home Care, LLC?(Required)

Newspaper

Trade Publication

Job Fair/Open House

Internet Site

Company Employee

Name:(Required)

I understand that I must report all accidents to my immediate supervisor and Over The Moon Home Care , LLC- - No MATTER

HOW SLIGHT.

Yes

I also understand that I must wear all required personal protection equipment (PPE).(Required)

Yes

The penalty for not wearing PPE is disciplinary action, up to and including termination.

Signature(Required)

ACKNOWLEDGMENT (Please read carefully and sign)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Over The Moon Home Care , LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked Over The Moon Home Care , LLC with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Over The Moon Home Care , LLC may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Over The Moon Home Care , LLC , its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Over The Moon Home Care , LLC, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Over The Moon Home Care , LLC or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Over The Moon Home Care , LLC, at any time, can constitute a contract of employment. No representative or agent of Over The Moon Home Care , LLC, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Over The Moon Home Care , LLC is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Over The Moon Home Care , LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

Applicant Signature(Required)

Date(Required)

Comments

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