ACCUCARE NURSING & HOMECARE Prospective employees will receive consideration without

20 Old Turnpike Rd., Nanuet NY 10954 discrimination because of race, creed, sex, age, national

(845) 624-0260 Fax (845) 624-0264 origin, handicap or veteran status.

APPLICATION FOR EMPLOYMENT

Last Name / First / Middle
Street Address / City / State / Zip
Home Telephone
( ) / Business Telephone
( ) / In Case of Interrupted Phone Service We Must Have a Neighbor's Phone # to contact you .
( )
Position Applied For / Pay Expected / Social Security #
Are You Over 21? [ ] Yes [ ] No Have You Ever Been Bonded? [ ] Yes [ ] No
Sex [ ] Male [ ] Female Have You Ever Worked With Us Before? [ ] No [ ] Yes If Yes, When/ How Long?
Have You Ever Been Convicted of a Crime in the Past 10 Years? (excluding traffic violations) [ ] No [ ] Yes
If Yes, List Convictions:
Do You Have Any Physical Handicaps Preventing You From Doing Certain Types of Work? [ ] No [ ] Yes
If Yes, Describe Handicap/ Limitations:
Have You Had Any Serious Illness in the Past 5 Years? [ ] No [ ] Yes
If Yes, Describe:
Hours Desired [ ] Part- time [ ] Full-time Shift Desired [ ] Days [ ] Evenings [ ] Nights
Days of the Week Available [ ] Sunday [ ] Monday [ ] Tuesday [ ] Wednesday [ ] Thursday [ ] Friday [ ] Saturday
How did you hear about us? ( ) Newspaper ( ) On-line (Internet) ( ) School
If your were referred by another nurse please give his/her name:

EDUCATION

School / Name and Location of School / Course of Study / No. of years
Completed / Did you
Graduate? / Degree or
Diploma
High School / [ ] Yes
[ ] No
College / [ ] Yes
[ ] No
Graduate / [ ] Yes
[ ] No
Business/ Trade/ Tech. / [ ] Yes
[ ] No

EMPLOYMENT HISTORY

1. / Company Name / Telephone
Address / Employed ( State month & year)
From To
Name of Supervisor / Weekly Pay
Start End
Job Title and Duties / Reason For Leaving

R/R 9/10

2. / Company Name / Telephone
Address / Employed From ( State month & year)
From To
Name of Supervisor / Weekly Pay
Start End
Job Title and Duties / Reason for Leaving
3. / Company Name / Telephone
Address / Employed From ( State month & year)
From To
Name of Supervisor / Weekly Pay
Start To
Job Title and Duties / Reason for Leaving

FOR OFFICE USE ONLY

Reference Checks / Date / Person Spoken To / Comments / Person Completing

PERSONAL REFERENCE

Name / Address / Relationship / Telephone No.

READ AND SIGN BELOW

The information provided by me in this application for employment is true and complete to the best of my knowledge. I understand that if I am employed, any false statements will be considered as cause for possible dismissal. You are hereby authorized to conduct any investigation of my personal history and/ or credit agencies or bureaus of your choice subject to the provisions of the Fair Credit Reporting Act.

______

SIGNATURE OF APPLICANT DATE

R/R 9/10