=>Homemaker/Companion or Certified Nursing Assistant in Grayslake Area (Lake County IL) at Right at Home

First Name *

Last Name *

Email *

Phone *

Full Address: *

How did you hear about us?

Check the position(s) you are applying for:

Homemaker/Companion
Personal Care Assistant / Certified Nursing Assistant

Select the type of Position(s) seeking:

Are you at least 18 years of age?

If hired, what are the days / times you are available to work?

Best time for us to call you?

What other languages do you speak?

If Other Language, please list:

If hired, can you provide proof of your legal eligibility to work in the United States?

If "No", please explain

Have you ever been convicted of a crime? (A “Yes” answer will not automatically disqualify you from employment, since the nature, date and the job you are applying for will also be considered).

If "Yes", provide details.

(Health Professionals Only) Have you ever been named in a medical-professional liability suit within the last five years?

If "Yes" to a liability suit, please explain.

(Health Professionals Only) Have you ever been disciplined by your state licensing board resulting in censure, probation, suspension, or revocation of your license or other disciplinary action?

If "Yes", please explain:

Did you graduate High School?

Did you graduate Nursing or Tech School?

(If applicable) List the Nursing/Tech School, City and State, Degree / Certificate

CERTIFICATIONS & Expiration Dates (ex: Basic Life Support, CPR, CNA, etc):

1. List your current / past Employer *

1. Position Held:

1. Compensation:

1. Address / City / State / Zip

1. Type of Facility:

1. Supervisor Name:

1. Supervisor Phone Number:

1. Dates of Employment (from _____ to _____)

1. Reason for Leaving?

2. List your past Employer:

2. Position Held

2. Compensation:

2. Type of Facility:

2. Address / City / State / Zip

2. Supervisor Name

2. Supervisor Phone Number:

2. Reason for Leaving?

2. Dates of Employment (from _____ to _____)

3. List your past Employer:

3. Position Held

3. Compensation:

3. Type of Facility:

3. Address / City / State / Zip

3. Supervisor Name:

3. Supervisor Phone Number:

3. Dates of Employment (from _____ to _____)

3. Reason for Leaving?

OPTIONAL Comments (example, you may provide additional experience here)

Reference 1 Name: *

Reference 1: Company / Relationship *

Reference 1: Phone Number of reference: *

Reference 1: Email Address (if known):

Reference 2: Name *

Reference 2: Company / Relationship: *

Reference 2: Phone Number of reference: *

Reference 2 Email Address (if known):

Reference 3: Name

Reference 3: Company / Relationship:

Reference 3: Phone Number of reference:

Reference 3: Email Address (if known):

This position will require a background check and a drug test, do you still want to apply? *

OPTIONAL: paste a copy of Resume

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I agree that all the above information is true and agree to the information in the hiring agreement: *

See all the jobs at Right at Home - Grayslake, IL here: http://RahNLC.recruiterbox.com/jobs

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