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Apply for CNA

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:CNA
ID:CNA 030626
Department:Clinical Services
Applicant Privacy Statement

By submitting my application I confirm that I have read and agree to the employer's applicant privacy statement:

Applicant Privacy Statement

Resume
Resume:
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* How long have you lived at this address:
* Previous address if you haven't lived at current address for at least 5 years.:
List previous addresses for past 5 yrs with the dates.
* Zip:
* Phone:
* Email:
Attachments
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Application for Employment
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
Yes   No
Home Health   CDS   In-homecare/Private duty

If you checked CDS above complete the following questions.

Yes   No
Yes   No
EMPLOYMENT DESIRED
Full Time   Part Time   Seasonal
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

*
*
*
Yes   No
*
*

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

*
*
*
*
*
*
*
*
*
Yes   No
*
*

Employer 2

*
*
*
*
*
*
*
*
*
Yes   No
*
*

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

*
*
*
*

Reference 2

*
*
*
*

Reference 3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

Place of residence
Your address for the last five years is needed to be considered for employment. Please enter it below.
* What is your current address?
* How long have you lived at this address?:
1-4yrs
5 yrs or more
* If less than 5 years, please list your address for the past 5 years.
HHA/CNA Skills Experience
Mark all that apply.

Mobility

* Do you have experience using mechanical lifts such as hoyer lifts and sit-to-stands?
Yes
No
* Do you have experience using a slide board?
Yes
No
* Do you have experience using a gait belt?
Yes
No
* Do you have experience assisting patients with meals such feeding them drinks and foods?
Yes
No
* Do you have experience measuring liquids and foods?
Yes
No
Do you have experience turning and repositioning a patient in bed and repositioning in a chair?
Yes
No
Choose all you have experience with.
Giving and assisting clients/patients with:
Complete Bed bath
Shower
Oral Hygiene
Peri-care
Toileting
* Do you have experience taking vital signs? Choose all that apply:
Taking blood pressures manually with a stethoscope?
Taking blood pressures with automated machines?
Measuring pulse rates on the patient's wrists?
Temperature?
Oxygen saturation?
* Do you have experience transferring a patient? Ex. moving a patient from wheelchair to bed or toilet.
Yes
No
Do you have experience transferring a patient who can't stand?
Yes
No
Relevant experience
Please indicate how many years of experience you have in this field.
* How many years of experience do you have working with the elderly population?:
No experience or less than 6months
6m-4yrs
5-10yrs
10+ yrs
Indicate the years of experience in home health.
no experience to less than 6m
6m-4yrs
5-10yrs
10+yrs
* Do you have any certifications such as CNA, CMT, LIMA, HHA?
* Do you have experience and know how to operate mechanic lifts such as hoyer lifts and sit-to-stands.
Yes
No
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female Male I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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