Online Application

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EMPLOYMENT/CONTRACTOR APPLICATION
PLEASE COMPLETE THIS APPLICATION AS COMPLETELY AND ACCURATELY AS POSSIBLE.

Education:	Did You Graduate?
PERSONAL INFORMATION	Date:

Last Name: First Name: Middle Name:

Address: City: State: Zip:

Social Security: Home Phone: Cell Phone:

Nursing License #: Email: Are you over the age of 18?

Are you a US Citizen? If no, do you have the legal right and necessary documents to work in the US? (Identity and employment eligibility will be verified as required by law.)

EMPLOYMENT INFORMATION

Position Desired: Part/Full Time: Shift Preference: Salary Requirement: $

Date available for work: Do you possess a valid driver's license? Driver's License #: Do you have your own transportation?

Have you applied here before? If Yes, When Did you Apply?:

Please explain how we were referred to you: How did you hear about JT Private Duty Home Care?

QUALIFICATIONS & EXPERIENCE

High School:
College:
Nursing School:
Technical Training:

Languages spoken in addition to English:

Can you perform all of the job-related functions of the position(s) for which you are applying? If no, please explain:

Do you have current CPR certification? Expiration date:

What shifts are you available for?

PAST & PRESENT EMPLOYERS

Current Employer: Name: Phone:
Full Address: Zip:
Position: Date started:
May we contact? Salary: $ Supervisor:

Past Employers: Name: Phone:
Full Address: Zip:
Position: Supervisor:
May we contact? Salary: $
Date started: Date ended: Reason for leaving:

Name: Phone:
Full Address: Zip:
Position: Supervisor:
May we contact? Salary: $
Date started: Date ended: Reason for leaving:

REFERENCES: (Give work or medical field related references. Do not list relatives or personal friends.) Name: Phone:
Full Address: Zip:
How I Know: Years acquainted:

Name: Phone:
Full Address: Zip:
How I Know: Years acquainted:

Name: Phone:
Full Address: Zip:
How I Know: Years acquainted:

CRIMINAL BACKGROUND INQUIRY

Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime? If yes, please explain: (You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.)

EMERGENCY CONTACT: Name: Home Phone:
Full Address: Work Phone:
Relationship to you:
"I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you." Electronic Signature: Date: Please enter the following validation code: Validation Code:

For More Information Call: (239)-896-6582
Assisted Living, Personal Assistance Care, 24 Hours a Day, 7 Days a week in Southwest Florida

JT Private Duty Home Care » Phone: (239) 896-6582 » Fax: (239) 645-4679
License #30211305 » Serving Lee & Collier Counties
JT Private Duty Home Care Copyright ©

JT Private Duty Home Care provides home assisted living, duty home care, elderly assistance, patient care, personal assitance, and after surgery care 24 hours a day seven days a week for Fort Myers, Sanibel, Naples, Lehigh, Bonita, Cape Coral, Lee and Collier Counties.