* = Required Information
Position applied for: * Date of Application:
Name: *
              (Last Name)
              (First Name & Middle Initial)
Home Phone #: * Cell Phone #: *
Next of Kin: Next of Kin Phone #:
Address: * City:
State: Zip Code:
Email Address: *
Have you ever been employed by A & V Homecare Services, Inc. before?
YesNo Date
Have you ever filed an application with A & V before? YesNo
Are you 18 years of age or older? * YesNo
What is your race/ethnicity?
Are you a U.S. citizen? * YesNo
If no, do you have legal right to work in the U.S.? YesNo
Have you ever been convicted of a crime? YesNo
Are you currently employed? YesNo
May we contact your present employer? YesNo
Work Availability
Start Date: *
Check which apply:
Days:
M T W Th
Fr Sat Sun
Live-in:
M T W Th
Fr Sat Sun
Shifts:
Days Evenings Nights
Do you have a car? * YesNo
Do you use public transportation? * YesNo
Licensure/Certification: (Please check which applies)
Licensure: RN
LPN
Medical Social Worker
Physical Therapist
Occupational Therapist
Speech Language Therapist
Certification:
QIDP HHA DSP CNA
License or Certificate # State Exp. Date
 
Do you have any physical, mental or medical impairment or disability that would limit your job performance for the position for which you are applying? YesNo
If yes, please explain:
Indicate what foreign languages you speak, read, and/ write:
Previous Employment: * (Please include name, address, telephone number, position held and dates)
1.
2.
3.
References: * (Name, address and telephone) (References may not be related to applicant.)
1.
2.
3.
Education School & Address Did you graduate? Type diploma/Degree
High School
College
Nursing School
Aide Training
Other:
Special skills and qualifications:
As the applicant, I hereby authorize A & V to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including reasons for such termination.
I certify that answers given are true. I authorize investigation of my statements and a criminal background check to be completed. False or misleading information may result in my discharge. I understand I am required to abide by the rules and regulations of the agency. I also understand that the agency is an Equal Opportunity Employer, and all applicants are considered for all positions without regard to race, color, religion, sex, national origin, age or marital status
Applicant's Name: * Date *