* = Required Information

Application for Employment

Infiniti Home Health Care is as Equal Opportunity Employer. Employment offers are made on the basis of qualifications, and without regard to race, sex, religion, national or ethnic origin, age, veteran status, or sexual orientation.

PLEASE TYPE OR PRINT. Complete the entire application. You may attach a resume, but you must still complete all questions; or your application will be deemed incomplete and may not be considered. Please fill out each box (don't just indicate "See Resume."). Application with missing or invalid job numbers will not be considered for any position.

Position Applying For *

Last Name *

First Name *

Middle Name *

Other names under which you have attended school or been employed

Street Address

City

State

Zip

Social Security Number

Home Phone

Work Phone

Other Phone

Are you eligible to work in the United States?

Yes

Are you 18 years of age or older?

Yes

What is you current age?

Have you ever been employed by Infiniti Home Health Care?

Yes

Date of employment and reason for leaving

Have you ever been convicted of a crime other than traffic offenses?

Yes

If YES, What was the nature of the offense, the date and the location.

if required for position, do you have a valid driver's license?

Yes

State of issuance, license number, and expiration

Other

EDUCATION

High School

Name of School

City/State

Did you graduate?

Yes

Number of years left to graduate

Date of Graduation

Degree received

Major

GED

Name of School

City/State

Did you graduate?

Yes

Number of years left to graduate

Date of Graduation

Degree received

Major

Other School

Name of School

City/State

Did you graduate?

Yes

Number of years left to graduate

Date of Graduation

Degree received

Major

College

Name of School

City/State

Did you graduate?

Yes

Number of years left to graduate

Date of Graduation

Degree received

Major

College

Name of School

City/State

Did you graduate?

Yes

Number of years left to graduate

Date of Graduation

Degree received

Major

College

Name of School

City/State

Did you graduate?

Yes

Number of years left to graduate

Date of Graduation

Degree received

Major

Other credentials/licenses/professional affiliations, etc., which are relevant to the job(s) for which you are applying

SKILLS: Please list clinical skills, technical skills, clerical skills, trade skills, etc., relevant to this position.

WORK EXPERIENCE Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission military or volunteer commitments. PLEASE DO NOT complete this information with the notation "See Resume." PLEASE NOTE Infiniti Home Health Care reserves the right to contact al current and former employers for reference information.

Dates Employed (most recent position)

From

Full time

Part time

Number of hours/weeks

Title

Starting Salary

Final Salary

Organization Name and Address

Supervisor's Name, Title and Phone Number

Other Reference Name, Title and Phone Number

Contact my current references

At any time

Only if I am a finalist candidate

Primary duties

Reason for Leaving

Dates Employed (most recent position)

From

Full time

Part time

Number of hours/weeks

Title

Starting Salary

Final Salary

Organization Name and Address

Supervisor's Name, Title and Phone Number

Other Reference Name, Title and Phone Number

Contact my current references

At any time

Only if I am a finalist candidate

Primary duties

Reason for Leaving

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION

I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or mission of facts, represents grounds for elimination form consideration for employment, or termination after employment if discovered at a later date. I authorize Infiniti Home Health Care to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit bacground investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document in NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contact for continued guaranteed employment. I understand that employees of Infiniti Home Health Care serve at-will, and the employment relationship may be terminated at any time by either party, or any no reason, other than a reason prohibited my law. If employed, I will be required to furnish proof of eligibility to work in the United States and to comply with agency regulations. I understand that the first SIX MONTHS of regular employment represent a provisional period, during which I would now be eligible to apply for transfer or promotion and during which I may be terminated without right of appeal.

Applicant Full Name

Date