Application For A Home Health Agency Aide Or Nurse in Hawaii

Personal Information

Position Seeking:
If "Other", please state what position you are applying for:
Have you applied for work here before: Yes: No:
Have you worked here before: Yes: No:
Are you legally authorized to work in the United States: Yes: No:
How did you hear of this job?

Full Name:
Street Address:
City:
State:
Zip Code:
Home Phone:
Email:

Were you previously employed or a student under another name? Yes No
If Yes, list full name and employer/school(s):

Experience:

(List all employers for at least the last 10 years, with the most recent first and account for any periods that you were not working)

Job 1 (click to expand/hide)

Employer Name:		Position:
Phone:		Address:
Start Date:		End Date:
City:		State:
Zip Code:		Supervisor:
Reason for Leaving:		Current or End Wage:

Job 2 (click to expand/hide)

Employer Name:		Position:
Phone:		Address:
Start Date:		End Date:
City:		State:
Zip Code:		Supervisor:
Reason for Leaving:		Current or End Wage:

Job 3 (click to expand/hide)

Employer Name:		Position:
Phone:		Address:
Start Date:		End Date:
City:		State:
Zip Code:		Supervisor:
Reason for Leaving:		Current or End Wage:

Job 4 (click to expand/hide)

Employer Name:		Position:
Phone:		Address:
Start Date:		End Date:
City:		State:
Zip Code:		Supervisor:
Reason for Leaving:		Current or End Wage:

Job 5 (click to expand/hide)

Employer Name:		Position:
Phone:		Address:
Start Date:		End Date:
City:		State:
Zip Code:		Supervisor:
Reason for Leaving:		Current or End Wage:

Job 6 (click to expand/hide)

Employer Name:		Position:
Phone:		Address:
Start Date:		End Date:
City:		State:
Zip Code:		Supervisor:
Reason for Leaving:		Current or End Wage:

Please detail any Care Giver or Related experience and skills (volunteer, at home, other employment, etc.) you may have or expand upon any employment references given above (1000 characters max):
If you wish to attach your resume, please send us an email.

Education:

High School:		Number of Years Attended:
Degree:
College:		Number of Years Attended:
Degree:
Others:		Number of Years Attended:
Degree:

Personal References (Not Family-Related or Former Supervisors)

Reference 1:
Name:
Phone:
Relationship:
Years Known:

Reference 2:
Name:
Phone:
Relationship:
Years Known:

Certificates and Licenses:

Hawaii Nursing License #:
Issue Date:
Expiration Date:
Nurse Aide Certification #:
State:
Issue Date:
Expiration Date:
TB Test/Chest X-ray:
Issue Date:
Expiration Date:
CPR:
Type:
Issue Date:
Expiration Date:

Availability:

Number of hours desired to work each week (range):
Wage Request (per hour):

Available hours to work each week:

	SUN	MON	TUE	WED	THUR	FRI	SAT
FROM:
TO:

I certify that the information contained on this application is true and complete to the best of my knowledge and understand that falsification of this information, whenever discovered, is grounds for dismissal. If I am offered employment, I consent to drug testing and to providing Attention Plus Care with an original Hawaii Criminal Conviction Record. I understand that I will be ineligible for employment if I refuse to undergo drug testing as directed, if I test positive for illegal drugs, or if I have a criminal conviction that has a rational relationship to the position being offered. I also understand that this application is not a contract and cannot create a contract. In addition, I understand that if I become employed, I will be free to terminate my employment at any time for any reason and Attention Plus Care retains the same rights.

I authorize the references listed above to give to Attention Plus Care any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from liability for any damage that may result from furnishing same to Attention Plus Care. I authorize the use of a photocopy of my signature in place of my original signature on documents pertaining to this authorization.

Employment Application