Employment Application - Epic Wellness - Home Health Care & Consulting

Basic Information

All fields in this section are required

Full Name*

Email*

ex. JoeSmith@gmail.com

Phone*

Position Desired*

CNA, HHA, RN, LPN, Housekeeper, Administrator, etc.

Date Available*

Let us know when you can begin

Full Address*

Street, City, State & Zip

Driver's License

Do you have a valid Driver's License?*
YesNo

Class

Driver's license number*

Ex. S91328862

Employment Questionnaire

Instructions

Each question is required to be answered. Answer yes or no to each question. Please fill out the optional detail field after answering each question.

Have you ever served in the military? *
YesNo

Do you speak any other languages? *
YesNo

If you do speak other languages, please specify:

Language and fluency level. Ex: "I can read, write and speak Spanish fluently. I can speak French but cannot read or write it."

Can you perform the essential functions and responsibilities of the position for which you are applying? *
YesNo

If not, please explain:

Do you require any special accommodation to perform required duties? *
YesNo

If yes, please explain:

Have you ever worked for EpicWellness? *
YesNo

If yes, give date(s) of employment and position(s) held:

Do any of your relatives work for EpicWellness? *
YesNo

If Yes, state their name(s):

Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation? *

If yes, written documentation will be required about criminal offenses from the clerk of court in the county in which the conviction was made, and about any driving offenses other than minor traffic violations from the mo‐ tor vehicles office.

YesNo

References (1 of 3)

Instructions

You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field.

Full Name*

Full Address*

Street, City, State & Zip

Phone*

Relationship *

Ex. Former boss, Co-worker, Teacher, Instructor, etc.

References (2 of 3)

Instructions

Full Name

Full Address

Street, City, State & Zip

Phone

Relationship

Ex. Former boss, Co-worker, Teacher, Instructor, etc.

References (3 of 3)

Instructions

Full Name

Full Address

Street, City, State & Zip

Phone

Relationship

Ex. Former boss, Co-worker, Teacher, Instructor, etc.

Education and Skills

Level of education completed *
GEDHigh SchoolCollege: 0-3 YearsCollege: Associates' DegreeCollege: Bachelors' DegreeCollege: Masters' Degree

If you have a degree, please specify major*

How many words per minute can you type?*

Only enter if known

Proficient software applications

Experience (1 of 3)

Instructions

Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom. If this is your first job, enter in your school graduation details below.

Start Date *

End Date *

Name of Employer *

May we contact your former employer? *
YesNo

Full Address*

Street, City, State & Zip

Supervisor's Name *

Phone Number*

Title and Duties Performed *

Reason for Leaving *

Experience (2 of 3)

Instructions

Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom.

Start Date

End Date

Name of Employer

May we contact your former employer?
YesNo

Full Address

Street, City, State & Zip

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

Experience (3 of 3)

Instructions

Tell us about your most recent jobs over the past 5 years. If you need more space use the notes section below the experience sections or attach a resume at the bottom.

Start Date

End Date

Name of Employer

May we contact your former employer?
YesNo

Full Address

Street, City, State & Zip

Supervisor's Name

Phone Number

Title and Duties Performed

Reason for Leaving

Experience: Additional Jobs

Tell us about any additional jobs in the past 5 years here

Sign and Submit

By submitting this form you agree

To carry out the designated responsibilities to the best of my ability. I have read the position description. I am aware there is a conditional period of 3 months prior to permanent employment. I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorized investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about my citizenship and employment history. I also certify that I understand all questions and statements on this application.

Checkbox *
Acceptance
I HAVE READ AND UNDERSTAND THE LEGAL INFORMATION ABOVE

Understandings & Signature

You understand that Epic Wellness will rely upon your electronic signature to the same extent as if you had signed this document in ink. If you do not understand or accept or agree to the terms and conditions set forth above, then do not submit. By entering the your name and date of birth below you signify that you understand and agree to the terms above.

Applicant's Signature *

Today's Date *

Upload Driver License

Upload Additional Documentation (such as certifications, licenses, etc.)

I have read and accept the Employee Handbook

I have read and accept the Elder Abuse Policy