Staff or Management Application Form

Staff or Management Application Form

Please complete the following application form and attach a resume.

Staff Employment Application - 2018 -

Please answer each question in a complete and accurate manner, attach your resume, then click submit. Required fields are indicated by a ( * ).

Our company is an equal opportunity employer and will consider all applicants for all positions equally without regard to race, sex, color, religion, national origin, veteran status, genetic information or any disability as defined by the Americans with Disabilities Act, or for any reason protected by State of Federal law. I understand that drug and alcohol tests, when given pursuant to company policy, are a condition of continued employment and refusal to take such tests when asked will be grounds for immediate termination.

  • Personal Information

  • School where you obtained degree or training for positions supporting and managing a Home Health Agency or similar business.
  • Please describe your medical support/management experience.
  • Employment History

    Do not reference your resume.
  • Additional Employment

  • Additional Employment

  • Certification and Release for Background Checks

  • CERTIFICATION AND RELEASE: I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing information about me. I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities, from any liability for any damage whatsoever for issuing this information. I further understand that the healthcare provider cannot provide a copy of this criminal history record check.
  • Please include any additional information we should be aware of when considering your application.
  • Max. file size: 256 MB.

After you click submit you will receive a “thank you for submitting your application” message. If you do not receive this message scroll up and correct your errors that will be highlighted in pink.

Download Our Free Brochure

    Inquire about help for you and your loved one

    or call our home care specialist at (407) 788-9393

    Your Name (required)

    Phone Number

    Your Email (required)

    Enter the Characters


    Your Message