Employment Application Apply Online Step 1 of 6 - Applicant Info 16% Position(s) applied for:(Required)Date of application(Required) MM slash DD slash YYYY Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) EducationPlease describe your educational background in the table provided below.Education Name of School: Years Completed: Degree/Diploma Received: Course of Study/Major: Specialized Training, Skills, or Extra-Curricular Activities Actions Edit Delete There are no Schools. Add School Maximum number of schools reached. Employment ExperiencePlease list the names of your present or previous employers in chronological order with present or last employer listed first. Be sure to account for all periods of time, include all employers for at least the last 5 years. Include all homecare and pediatric experience. If self-employed, give firm name and supply business references.Previous Employers Employer Address Job Title Actions Edit Delete There are no Employers. Add Employer Maximum number of employers reached. Have you ever been involuntarily terminated or asked to resign from any job?(Required) Yes No If yes, please explain.Please explain any gaps in your employment history:Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment. ReferencesBusiness and Professional ReferencesPlease list three professional references of individuals who are not related to you. Name Relationship: Phone or Email Actions Edit Delete There are no References. Add Reference Maximum number of references reached. Personal ReferencesPlease list three people who know you well. Name Relationship: Phone or Email Actions Edit Delete There are no References. Add Reference Maximum number of references reached. Have you ever used another name?(Required) Yes No If yes, please list.Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?(Required) Yes No If yes to either of the above, please explain:Have you ever worked for this company before?.(Required) Yes No If yes to either of the above, please explain:Do you have friends and/or relatives working for this company?(Required) Yes No If yes to either of the above, please explain:On what date are you available to begin work?(Required) MM slash DD slash YYYY Days/Hours available to work:(Required)Available to Work:(Required) Full-time Part-time Shift work Temporary Minimum salary required per monthMinimum salary required per hourIf hired, would you have a reliable means of transportation to and from work?(Required) Yes No Can you travel if the position requires it?(Required) Yes No Are you at least 18 years old?(Required)If under 18, hire is subject to verification that you are of minimum legal age. Yes No If hired, can you present evidence of your identity and legal right to work in this country?.(Required) Yes No Are you able to perform the essential job functions of the job for which you are applying with or without reasonable accommodation?(Required)We comply with the ADA and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions. Yes No Applicant Statement and AgreementPlease read and check each paragraph below. If there is anything that you do not understand, please ask. Consent(Required)I hereby authorize NextStep Homecare, Inc. to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to NextStep Homecare, Inc. any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release NextStep Homecare, Inc., my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I agree(Required)Consent(Required)In the event of my employment with NextStep Homecare, Inc., I understand that I am required to comply with all rules and regulations of NextStep Homecare, Inc. I agree(Required)Consent(Required)If hired, I understand and agree that my employment with NextStep Homecare, Inc. is at-will, and that neither I, nor NextStep Homecare, Inc. is required to continue the employment relationship for any specific term. I further understand that NextStep Homecare, Inc. or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications. I agree(Required)Consent(Required)I understand that safety of employees is extremely important to NextStep Homecare, Inc. and that NextStep Homecare, Inc. is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health. I agree(Required)Consent(Required)I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I agree(Required)Consent(Required)I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard. I agree(Required)Consent(Required)I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed and the remainder of this Agreement shall be enforceable. I agree(Required)Resume or Cover Letter (optional) Drop files here or Select files Accepted file types: jpg, png, pdf, , Max. file size: 300 MB, Max. files: 3. MY SIGNATURE BELOW ATTESTS TO THE FACT THAT I HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE TERMS.(Required)Date MM slash DD slash YYYY Δ
