Omnipresence Healthcare Agency LLC

PART A: PERSONAL INFORMATION

Applied For?

Title: Mr. /Miss /Mrs.

Forename(s):

Surname:

Home Address:

Correspondence Address (If different:

Home Telephone:

Work Telephone:

May we contact you at work?

Date of Birth:

Are you a citizen of the United States?

If no, are you eligible to work in the United States?

Do you have a work permit or a right to work Visa?

Have you ever been convicted of a misdemeanor or felony?

If yes, please explain the circumstances of the conviction.

PART B: EDUCATION AND TRAINING

High School Name and Address

Dates Attended:

Diploma Received?

Area of Study

Colleges/ Training Schools

Dates Attended:

Diploma Received?

Area of Study

Professional trainings/ qualifications with dates and levels obtained

PART C: PRESENT AND PAST WORK HISTORY

Present or most recent employer and address:

Dates (month/year):

Position Held and Duties:

Reason for leaving:

Starting Salary:

Ending Salary:

May we contact this employer?

If no, please indicate reason.

PART D: WORK HISTORY (1)

Give details of your work history with the most recent listed first:

Employer and address:

Dates (month/year):

Position Held and Duties:

Reason for leaving:

Starting Salary:

Ending Salary:

May we contact this employer?

If no, please indicate reason.

PART D: WORK HISTORY (2)

Give details of your work history with the most recent listed first:

Employer and address:

Dates (month/year):

Position Held and Duties:

Reason for leaving:

Starting Salary:

Ending Salary:

May we contact this employer?

If no, please indicate reason.

PART E: SUPPORTING STATEMENT

Please indicate all relevant experience, skills and work history that relate to the job description for which you have applied. Please print clearly. All illegible entries will not be considered.

PART F: MEDICAL HISTORY

What absences due to illness have you had from work for the last two years?

Do you have any illness that will prevent you from performing the duties of the position of which you have applied?

If yes, please indicate

Can you lift a weight of seventy pounds?

PART G: REFERENCES

Please list three professional references of which we may contact.

Name

Relationship

Years of Affiliation

Telephone number

Name

Relationship

Years of Affiliation

Telephone number

Name

Relationship

Years of Affiliation

Telephone number

PART H: DECLARATION

I here by certify that all information included in the above application is true and valid to the best of my knowledge. I also understand that misrepresentation or falsification of the information provided above will result in my immediate disqualification from the selection process and dismissal from any Position appointed to by the Agency after discovery.

Name

Date

Careers

EMPLOYMENT APPLICATION FORM

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