Application Page

Please allow enough time to complete form in full. Do NOT use the back button during process. Items in red are required, you may be asked to return if left blank.

Personal

Personal Information

Last Name:

First Name:

M.I.:

Other Names Used:

Street Address:

Apt:

City:

State:

Zip:

Mailing Address (if different):

Apt:

City:

State:

Zip:

Email Address:

Cell Phone:

Home Phone:

Are you available for work on weekends?

YesNo

Would you be available to work overtime, if necessary?

YesNo

If hired, on what date can you start work?

Have you ever applied to or worked for All Health Services or one of our clients (including the State of California, or one of its counties)?

YesNo

If yes, when, where, and what position?

Please list any counties in which you have lived during the last seven years, including where you live now:

Background

Background Information

Do you have any friends or family members who work for All Health Services? If yes, state name(s) and relationship:

YesNo

If yes, state names and relationships:

Have you obtained any special skills as the result of service in the military?

YesNo

If so, describe:

If hired, would you have a reliable means of transportation to and from work?

YesNo

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)

YesNo

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?

YesNo

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?

YesNo

If no, describe the functions that cannot be performed.

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)?

YesNo

If yes, state nature of crime(s), when and where convicted, and disposition of the case.

Do you speak, write, or understand any foreign languages?

YesNo

If yes, which language(s)?

Do you have any other experience, training, qualifications, or skills that you feel make you especially suited to work with All Health Services?

YesNo

If so, please explain?

Certifications

Certifications Information

License/Certification (i.e. PT, RN, LVN, CNA, MA)

License/certification number:

Expiration Date:

Has your license/certification ever been revoked or suspended?

YesNo

If yes, state reason(s), date of revocation or suspension, and date of reinstatement.

Please list additional license/certifications/credentials (i.e. CCRN, PALS, ACLS, OCN, etc.). In your list, please include dates and reference numbers, if applicable. Be sure to include legible copies with your application!

Education

Education Information

High School

Name

Degree or Diploma:

Start:

End Date:

Graduated: YesNo

Address

City

State

Zip

College/University

Name

Degree or Diploma:

Start:

End:

Graduated: YesNo

Address

City

State

Zip

Vocational/Business School

Name

Degree or Diploma:

Start:

End:

Graduated: YesNo

Address

City

State

Zip

Health Care Training

Name

Degree or Diploma:

Start:

End:

Graduated: YesNo

Address

City

State

Zip

Professional References

References Information

Reference 1

First Name:

Last Name:

Title:

Your Title During Relationship:

Facility Name:

Address:

City:

State:

Zip:

Work Phone:

Cell Phone:

Start and end dates of professional relationship:

Start Date:

End Date:

Reference 2

First Name:

Last Name:

Title:

Your Title During Relationship:

Facility Name:

Address:

City:

State:

Zip:

Work Phone:

Cell Phone:

Start and end dates of professional relationship:

Start Date:

End Date:

Reference 3

First Name:

Last Name:

Title:

Your Title During Relationship:

Facility Name:

Address:

City:

State:

Zip:

Work Phone:

Cell Phone:

Start and end dates of professional relationship:

Start Date:

End Date:

Employment

Past Employment

Current or Recent Employer

Name:

Telephone No.:

Type of Business:

Supervisors Name:

Address:

City:

State:

Zip:

Dates of Employment: From:

To:

Your position and duties:

Reason for leaving:

May we contact this employer for a reference?

YesNo

Previous Employer

Name:

Telephone No.:

Type of Business:

Supervisors Name:

Address:

City:

State:

Zip:

Dates of Employment: From:

To:

Your position and duties:

Reason for leaving:

May we contact this employer for a reference?

YesNo

Previous Employer

Name:

Telephone No.:

Type of Business:

Supervisors Name:

Address:

City:

State:

Zip:

Dates of Employment: From:

To:

Your position and duties:

Reason for leaving:

May we contact this employer for a reference?

YesNo

Documents

Hold shift to upload multiple files.

Professional License:

Driver License/Identification:

Certificates:

Resume:

Cover Letter:

Finalize

Please Read Carefully, Check Each Paragraph and Sign Below

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the information given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I further authorize All Health Services to disclose any documents, forms, or information obtained during this application process to any client to which I may be considered for work.

To All Health Services and the facilities to which it presents me for work, I give authorization to thoroughly investigate my references, work record, Licensure/Certification, education and other materials related to my suitability for employment and, further, authorize the references I have listed to disclose All Health Services any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release All Health Services, my former employers and all other persons, corporations partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and All Health Services. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or All Health Services and that no promises or representations contrary to the foregoing are binding on All Health Services unless made in writing and signed by me and All Health Services' designated representatives.

Should a search of public records (including driving records, tax records, court or criminal records or any other public record) be conducted by internal personnel employed by All Health Services, I am entitled to copies of any such public records obtained by All Health Services unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the box below.

I waive my right to receipt of a copy of any records described in above paragraph.

Date:

Signature:

Please allow enough time to complete form in full. Do NOT use the back button during process. Items in red are required, you may be asked to return if left blank.

Personal

Personal Information

Are you applying for:

Background

Background Information

Certifications

Certifications Information

Education

Education Information

Professional References

References Information

Employment

Past Employment

Documents

Documents

Finalize

Please Read Carefully, Check Each Paragraph and Sign Below