Are you a passionate nurse, home health aide, physical therapist, or other healthcare professional?

Help us carry out our mission of consistent, compassionate home healthcare that promotes dignity and trust among patient, caregivers and clinicians alike.

Application For Employment

Personal Information

Present Address

Permanent Address (If different than present address)

If you cannnot be reached at above phone number, where may we contact you?

Will You Accept Employment of:

Full Time
Part Time
Temporary

Are you 18 Years, Of Age or Older?

Not selectedYesNo

Are you Employeed Now?

Not selectedYesNo

May We contact Your Present Employer?

Not selectedYesNo

How Did You Learn Of This Opening?

Education

Select Highest

Not selected(GED)9101112 

College Completed

Not selectedAssc.Bach.Masters 

Scholastic Honors Recieved

High School

College

Vocational or Business

Completed
Not selectedYesNo 

Professional Education

Completed
Not selectedYesNo 

Laboratory or X-Ray Training

Completed
Not selectedYesNo 

Were you in the U.S Armed Forces?

 Not selectedYesNo 




Professional Licenses and/or Certifications













Employment Record (list last or present position first)

Present and Former Employers






Dates Employed



Salary Range





Present and Former Employers






Dates Employed



Salary Range





Present and Former Employers






Dates Employed



Salary Range





Present and Former Employers






Dates Employed



Salary Range




If your former employment references, education, or military service are under a name other than indicated on front of application, please indicate below




Have you ever been convicted of a crime?

Not selectedYesNo

A conviction will not necessarily preclude your employment.


Please Indicate Days and Hours You Are Available For Work (Be Specific)

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Availability Record


Will you accept another position:

Not selectedYesNo


Are you available to work:

Weekends?

Not selectedYesNo

Holidays?

Not selectedYesNo

Rotating Shifts?

Not selectedYesNo

If your availability changes, it is your responsibility to fill in an "Availability Card" indicating the changes. Such changes will be effective, then, for any future employment.

I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling changes as directed by my department head or administrator of this institution.



Employment Understanding (Please Read and Sign)

This Institution does not discriminate when hiring or any in other decision-making process on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam veteran status, or on the basis of age or physical or mental disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take a physical examination, and any future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form I-9 and within three days show satisfactory evidence of identity and eligibility for employment.

You understand that Better Care 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 in this document, then do not submit. By entering your name and date of birth below you signify that you understand and agree to the terms of this form.