* = Required Information

Date

Full Name *

Address *

City *

State

Zip *

Social Security Number *

Date of Birth *

Home Phone *

Cell Phone *

Email Address *

Position Desired *

Salary Expectation *

Applying For

Indicate days and hours available to work

Sun	Mon	Tue	Wed
Thu	Fri	Sat

Time

Are you willing to work weekends,holidays, on-calls?

YesNo

How are you referred to us?

When would you be able to start?

Employer's/Company Name

From

Telephone

Address

City

State

Zip

Job Title

Ending Salary

Shift

Duties and Responsibilities

Registry

Supervisor's Name

Phone Number

Reason for Leaving

Voluntary or Involuntary

VoluntaryInvoluntary

May we contact?

YesNo

Employer's/Company Name

From

Telephone

Address

City

State

Zip

Job Title

Ending Salary

Shift

Duties and Responsibilities

Registry

Supervisor's Name

Phone Number

Reason for Leaving

Voluntary or Involuntary

VoluntaryInvoluntary

May we contact?

YesNo

Employer's/Company Name

From

Telephone

Address

City

State

Zip

Job Title

Ending Salary

Shift

Duties and Responsibilities

Registry

Supervisor's Name

Phone Number

Reason for Leaving

Voluntary or Involuntary

VoluntaryInvoluntary

May we contact?

YesNo

Employer's/Company Name

From

Telephone

Address

City

State

Zip

Job Title

Ending Salary

Shift

Duties and Responsibilities

Registry

Supervisor's Name

Phone Number

Reason for Leaving

Voluntary or Involuntary

VoluntaryInvoluntary

May we contact?

YesNo

Employer's/Company Name

From

Telephone

Address

City

State

Zip

Job Title

Ending Salary

Shift

Duties and Responsibilities

Registry

Supervisor's Name

Phone Number

Reason for Leaving

Voluntary or Involuntary

VoluntaryInvoluntary

May we contact?

YesNo

Are you legally eligible for employment in the United States?

YesNo

Have You ever been convicted of crime at any time (other than minor traffic violation)? A conviction (misdemeanor or felony includes a plea of "guilty" or "no contest". A yes will be considered for job related purposes only and will not automatically disqualify you from employment.)

YesNo

If yes, please explain

Do you have any relative working for Corlan Home Health Inc.?

YesNo

Do you have previous employment existing under different Name?

YesNo

If yes, provide name

Do you feel you can safely and efficiently perform the essential requirements of the job for which you are considered?

Name & Address of School

Major Area of Study

Years Attended

Did you graduate?

YesNo

List Diploma or Degree

Name & Address of School

Major Area of Study

Years Attended

Did you graduate?

YesNo

List Diploma or Degree

Name & Address of School

Major Area of Study

Years Attended

Did you graduate?

YesNo

List Diploma or Degree

Are you currently

RegisteredLicensedCertified

Eligible for

RegistrationLicensureWill take boards

List Dates (Will take board)

Type

State Issued

Date Expires

Number

Type

State Issued

Date Expires

Number

Typing wpm, Data Entry, Medical Transcription, Shorthand/Dictaphone, Computer Skills.

List of office machines or mechanical equipment you are capable of using

Do you have experience with Microsoft Office Products?

YesNo

List any other experiences, skills or qualifications, which you want to describe (include software application for which you would rate yourself competent)

I understand that any false statement or material omissions made as part of this application will disqualify me from further consideration for employment and, if discovered later, will be grounds for discharge. I also understand that any offer of employment is contingent upon the results of pre-employment medical examination, drug screen, criminal background check and reference check. I authorize my former employers to release all information concerning my employment. I further authorize the release of any such information during or after my employment, without any prior notification. This authorization releases the aforesaid parties and Corlan Home Health, Inc. (CHH Inc) from any Liability for the collection and reporting of information.

Corlan Home Health, Inc. does not discriminate in hiring or employing on the basis of sex, color, mental status, religion, sexual orientation, national origin, age, disability, military status or any other protected category. No question on this application is intended to secure information to be used such discrimination.

I understand that if' am employed by CHH Inc., my employment is "at will" and may be terminated by me or by HHC Inc., at any time with or without cause, for any reason. No one other than the President of CHH Inc., has the authority to enter into an agreement contrary to the foregoing and any such agreement must be in writing and signed by both the President and me.

Full Name *

Date