Application Form

Please fill this out and click the "Submit" button at the bottom when done.

All fields marked with * are required.

Position

What position are you interested in?
If you are applying to work for a specific client, check here

Person Requesting Forms

First Name *	Middle Name
Last Name *	Sex Male Female

Please provide the following contact information:

Street Address *
City *	State/Province *
ZIP/Postal Code *	County
Cell Phone	Home Phone *
E-mail *

Are you Bilingual?
No Yes

If yes, please list languages you speak fluently:

Education (complete if not included on uploaded Resume)

In the spaces below, please enter schools you have attended (including high school), start with the most recent one

School/City/State	Years Completed	Degrees Received	Course of study (Major/Minor)

Professional Licenses (complete section)

Do you have a professional License, certificate and or registrations? Yes No

License/Certificate/Registration #	Type	State Issued	Date Expires

Work Experience (complete if not included on uploaded Resume)

Please start with the present or most recent employer(s)

Employer 1:

Employer:
City/State:
Start Date:	(mm/yy)
End Date:	(mm/yy)
Job Title:
Average Hours per Week:	(Complete section if applying for any field position)
Supervisor/Title:
Supervisor’s Phone:
Duties:
Reason for Leaving:
May we contact your current employer?	Yes No

Employer 2:

Employer:
City/State:
Start Date:	(mm/yy)
End Date:	(mm/yy)
Job Title:
Average Hours per Week:	(Complete section if applying for any field position)
Supervisor/Title:
Supervisor’s Phone:
Duties:
Reason for Leaving:
May we contact your employer?	Yes No

Employer 3:

Employer:
City/State:
Start Date:	(mm/yy)
End Date:	(mm/yy)
Job Title:
Average Hours per Week:	(Complete section if applying for any field position)
Supervisor/Title:
Supervisor’s Phone:
Duties:
Reason for Leaving:
May we contact your employer?	Yes No

Clinical Skills (complete section if applying for RN/LPN/PCA position)

Please complete this form in the following manner: if you have had consistent experience in the following areas within the past 6 months to 1 year.

Certifications:	IV CPR
Tracheostomy:	Child Tracheostomy Adult Tracheostomy Trach Changes Sterile Deep Tracheostomy Suctioning Tracheal Suction Trach/Stoma care/Changing trach ties Ambu bag/manual ventilation Trach collar with heated humidity
Gastrostomy Experience:	Gastrostomy tube/Gastrostomy site cares Mic-Key experience Feeding pump experience Peg Gastrostomy Administering meds via Gastrostomy
Pulmonary/Oxygen Therapy:	Nebulization treatments Oxygen Suction machines Chest physiotherapy Breath sounds
Cardiac Exerience:	Heart sounds Blood pressure Dinnemap/Doppler Palpation
Ventilator Experience:	Vent Experience Vent Weaning CPAP BiPap Pulmonetic Ventilator experience Newport Ventilator experience T-Bird ventilator Experience Other Ventilator
Other Experience:	Catherization Central lines Peripheral lines Ostomy Cares Infusion therapy Foley catheter experience

Miscellaneous Questions (complete section)

What Shift are you willing to work?	(Complete section if applying for any field position)
What Shift length are you willing to work?	(Complete section if applying for any field position)
What is your desired compensation?
How far are you willing to drive (miles)?	(Complete section if applying for any field position)
How did you hear about Accurate Home Care?
* Have you ever been convicted of a misdemeanor?	No Yes
* Have you ever been convicted of a felony?	No Yes
If YES, please describe here:

Attach Resume (optional)

Click Browse to upload Resume. Note: File must be LESS THAN 500K (1/2 meg) in size. Your resume must be in one of these formats: Microsoft Word, Adobe PDF, Plain Text or Rich Text.

Attach Resume File:

I understand that any agreement of employment entered into between AHC and me is predicated upon the truthfulness of the statements herein contained. I am not aware of any legal, contractual or other restrictions on my ability to perform the duties of the position I am applying for. I understand that my previous employers may be asked for information relative to my employment record with them. I hereby release from all liability or damage those individuals or corporations who provide such information relating to my prior employment or character.

I understand that it may be necessary for AHC to obtain additional information through a credit report and/or background investigation. Facts and references on my application would be used in this investigation. I understand that I may not be hired through AHC or any of its affiliates before an interview has occurred and references have been checked. I have the right to make a written request within a reasonable period of time to receive addition, detailed information about the nature and scope of this investigation. It is understood and agreed that any misstatement made by me in this application would be sufficient cause for discharge. Furthermore, I understand that if I am employed by AHC, my employment is at will and may be terminated by either myself or AHC at any time. In any event all obligations on the Company’s part as to my salary shall end with the last day that I work.

Accurate Home Care wants to "Thank you!!" for taking the time to fill this out...Please click the "Submit Form" button below to send it to us. You will then be brought back to the "Employment" page.

***Important***
We will be entering your information into our database for same day or future reference to clients that fit your descriptions above. Please make sure you fill it out every question. We will also be contacting you by email or phone within one week.

I have carefully read the above acknowledgement and I understand and agree to all of the statements. I also state that the information provided by me in this application are true, complete and correct to the best of my belief and knowledge.

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