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Application for Employment

Employer's Statement

Please print clearly. This application must be completed and all the questions regarding your training and work experience must be answered. All information on this application is confidential, Prime Home Health Services LLC. will not contact your present employer without your consent. In accordance with federal, state, and local laws, Prime Home Health Services LLC. does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, age, disability, or any other legally protected status. Applicants may request any reasonable accommodation to participate in the application process.

School, City, and State of School # of Years
Degree/Diploma/Certification Graduated?
Yes or No
Major Course of Study
Professional Licenses and/or Certificates
CPR, PT, RN, HHA, CNA etc.
Agency/State Issued Date Issued Expiration Date Lic Number *Office Use Only*
Enter date and Initials of person verifying

*Please begin with your most recent employment and proceed back to at least 10 years of Employment History

Employment History
Employment History
Employment History

Applicant’s Statement
I hereby affirm that the information provided on this application) and accompanying resume, if any) is true and complete to the best of my knowledge. I also understand and agree that any falsified information or significant omissions may disqualify me from further consideration for employment and, if discovered after 1 am hired, may result in dismissal.
I also understand that id employment is offered and accepted such employment is not for any specified term and can be terminated at anytime, with or without cause, either by Prime HHS or me. I further understand that this application is not a contract of continued employment, and that my at-will employment status cannot be changed.
In consideration of my being considered for employment, I authorize a thorough investigation of my past employment and activities. I agree to cooperate in such investigation, and release from all liability all persons and businesses requesting or supplying such information.
I understand that Prime requires that a Criminal History Check be conducted on persons to whom an offer of employment is made, if the person's duties will involve any direct patient contact, including telecommunications, with any patient, patient's family, or patient's visitors, or the property of such persons. I also acknowledge that Prime requires a Drug Screening to be conducted on persons to whom an offer of emp loyment is made,
By signing this application, I acknowledge that I have been informed by prime HHS that a criminal history check will be performed along with a Drug Screening. I have informed Prime HHS of all names, (i.e., maiden, aliases) that I have used in the past. I understand that I may be employed on an emergency basis and that my employment mav be temporarv pending the results of mv criminal history check and Driio Screening,

***** OFFICE USE ONLY *****

Computer Skills Assessment

**Please rate yourself as a computer user by indicating the appropriate level**

Function Beginner Skilled Proficient
Turn on a computer Beginner Skilled Proficient
Knowledge of a keyboard Beginner Skilled Proficient
Working with a mouse Beginner Skilled Proficient
Functions of the computer screen Beginner Skilled Proficient
Using Icons and Creating desktop shortcuts Beginner Skilled Proficient
Accessing features using the start button Beginner Skilled Proficient
Accessing features using the start button Beginner Skilled Proficient
Working with multiple programs by using the taskbar Beginner Skilled Proficient
Use of the My Computer Icon to access the drives Beginner Skilled Proficient
Using Microsoft Outlook for emails Beginner Skilled Proficient
Reading, composing and sending emails in Microsoft Outlook Beginner Skilled Proficient
Responding and forwarding emails in Microsoft Outlook Beginner Skilled Proficient
Using Internet Explorer Beginner Skilled Proficient
Use of the Recycle Bin Beginner Skilled Proficient
Copying and Pasting sections of text Beginner Skilled Proficient
Opening and closing programs Beginner Skilled Proficient
Customizing the computer desktop Beginner Skilled Proficient
Using keyboard shortcuts Beginner Skilled Proficient
Creating a Microsoft Word document Beginner Skilled Proficient
Shutting down or logging off from the computer Beginner Skilled Proficient

Please circle the correct answer.