Employment Application Ohio Valley Home Health & Home Care is now hiring all positions. Please complete and submit application below. Personal InformationFirst Name *Middle NameLast Name *Address *City *State *ZIP *Email *Phone *SSNDiscipline License NumberEmployment InformationPosition DesiredPart-timeFull-timeWhat area are you applying for?Home Health CarePersonal/Home CareShift PreferenceDate Available for WorkDo you possess a valid driver’s license? *YesNoDo you have your own transportation? *YesNoHave you applied here before? *YesNoHave you ever been convicted of a felony or misdemeanor? *YesNoDetails(You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.)Qualifications & ExperienceSchool & Years AttendedDid you graduate?High SchoolDid you graduate?YesNoCollegeDid you graduate?YesNoNursing SchoolDid you graduate?YesNoTechnical TrainingDid you graduate?YesNoDo you have any physical limitations that would prevent you from performing the work for which you are applying? *YesNo(75 lb. weight limit)ExplainDo you have CPR certification? *YesNoBriefly describe your experience in the health care field. *Why do you want to work for this agency *Past & Present EmployersCurrent EmployerAddressCityStateZIPPhoneDatePositionSupervisorSalaryUSDMay we contact?YesNoPast EmployerAddressCityStateZIPPhoneDatePositionSupervisorSalaryUSDMay we contact?YesNoPast EmployerAddressCityStateZIPPhoneDatePositionSupervisorSalaryUSDMay we contact?YesNoReferences(Please do not list relatives or personal friends)ReferenceNameAddressCityStateZIPPhoneHow I knowYears knownReferenceNameAddressCityStateZIPPhoneHow I knowYears knownReferenceNameAddressCityStateZIPPhoneHow I knowYears knownEmergency ContactName *Address *Phone *Relationship to you *I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you. SubmitPlease do not fill in this field.
