Ambassador Home Health Online Employment Application

Complete this application package carefully. Your completed forms will be used to examine your qualifications. It is in your best interest to answer all questions. Omission of an item means you might not receive full consideration for a position in which this information is needed. A misstatement of material facts on the employment forms may be used as grounds for not employing you or for dismissing you after you begin work. All statements are subject to investigation. All information you give will be considered in reviewing your application for employment. Federal law prohibits discrimination in all employment practices because of race, color, religion, sex, national origin, age or disability. No question on this application is intended to secure information to be used for such discrimination.

Position Applied For:

Date:

 

Personal

Last Name, First, Middle:

Email Address:

Street Address:

Home Telephone:

City:

State: Zip:

Business Telephone:

Have you ever been employed with AHHC?

Yes No – If yes: Dates of employment: Position:

When will you be available to begin work?

 

General

Do you have a legal right to work in the United States?

Yes No

If so, are you able, after employment, to submit verification of your legal right?

Yes No

Are you at least 18 years of age?

Yes No

If under 18 years of age, are you able to submit necessary permits for employment?

Yes No

Have you ever been convicted of a felony?

Yes No

If yes, please explain, and give city, state and dates.

Note: This question does not apply to convictions that have been sealed or erased. A conviction will not necessarily be a bar to employment. Do you have any relatives employed by the Ambassador Home HealthCare?

Yes No

If yes, please list their names and relationship to you.

Some positions require a valid driver license. If the position(s) you are applying for requires a driver license: Do you have a valid driver license?

Yes No

License I.D. Number:  Issuing State:
Expiration Date:

 

Education

School

Name & Address

Course of Study

No. of Years Completed

Did You Graduate?

Degree or Diploma

Elementary

 

High School

 

Business Trade / Technical School

College

Graduate School

 

Are records that will verify your education and/or employment listed under a different name? Yes No

If yes, indicate school/job affected and name used.

ALL EDUCATION IS SUBJECT TO VERIFICATION

 

Technical Skills, Licenses, Certificates

 

Membership in Professional or Civic Organizations
(Exclude those which may disclose your race, color, religion, national origin, sex, age or disability)

 

ALL PREVIOUS EMPLOYMENT IS SUBJECT TO VERIFICATION

Please give complete information. A resume may be attached but cannot be substituted for required information. Start with your current or most recent employer. Include military and volunteer activities. Account for all periods of unemployment.

 

Employment
Company Name

Telephone

Address

City
, Zip

Employed - State Month/Year

From to

Name of Supervisor

Salary

Start Last

State Job Title and describe your work:

Full Time Part Time Volunteer

Reason for leaving

 

Company Name

Telephone

Address

City
, Zip

Employed - State Month/Year

From to

Name of Supervisor

Salary

Start Last

State Job Title and describe your work:

Full Time Part Time Volunteer

Reason for leaving

 

Company Name

Telephone

Address

City
, Zip

Employed - State Month/Year

From to

Name of Supervisor

Salary

Start Last

State Job Title and describe your work:

Full Time Part Time Volunteer

Reason for leaving

 

Company Name

Telephone

Address

City
, Zip

Employed - State Month/Year

From to

Name of Supervisor

Salary

Start Last

State Job Title and describe your work:

Full Time Part Time Volunteer

Reason for leaving

 

Company Name

Telephone

Address

City
, Zip

Employed - State Month/Year

From to

Name of Supervisor

Salary

Start Last

State Job Title and describe your work:

Full Time Part Time Volunteer

Reason for leaving

 

Company Name

Telephone

Address

City
, Zip

Employed - State Month/Year

From to

Name of Supervisor

Salary

Start Last

State Job Title and describe your work:

Full Time Part Time Volunteer

Reason for leaving

 

May contact be made with your present employer at this time to verify employment and qualifications?

Yes No - If NO, employment verification will be required if you are selected.

 

APPLICANT CERTIFICATIONS

By clicking here I certify that I have read and understand the below statements:

I understand that neither this application nor any communication by a Ambassador Home HealthCare(AHHC) representative is intended to create or creates a contract of employment. I understand that employment with AHHC may be terminated at any time at the option of either AHHC or myself.

I authorize the release of information from the following sources to AHHC:

  • Past and present schools regarding academic records.
  • Past and present employers regarding employment.
  • The Ohio Bureau of Criminal Identification regarding criminal history record.
  • The Ohio Bureau of Motor Vehicles regarding driving record.

And I release AHHC and any of the above sources who provide information to AHHC from any and all liability whatsoever resulting from such information.

I certify that all information I have provided in this application is complete and true to the best of my knowledge. I understand that, if I am hired by AHHC, the discovery of any misrepresentation or the omission of the facts in this application will be cause for my immediate dismissal.

Date