Position Type:* --- CHHA (Certified Home Health Aide) DSP 'Direct Support Professional' Others Full Name:*
Are there any other names/ nicknames you’ve used in the past?* Yes No
Address:*
Home Phone #:*
Cell Phone #:*
SS # or last 4 digits:*
Date of Birth:*
Email Address:*
Emergency Contact Name *
Number
Have you ever been employed by Excellent Home Health Care before?* Yes No Date
Have you ever filed an application with Excellent Home Health Care before?* Yes No
Are you of 18 years or older?* Yes No
Are you currently employed? Yes No
May we contact your present employer? Yes No
Start Date:
Days of the Week:
Live-In:
Shifts:
Do you have a car? Yes No
Do you use public transportation? Yes No
Licensure: RN LPN Social Worker PT OT ST
Special Certifications:
Certification: CHHA CNA
License or Cert #:
State:
Board/lic auth:
Exp.Date:
Malpractice Insurance (if applicable) policy number:
Do you speak, read and understand English: Yes No
Indicate what foreign languages you speak, read, and/ write:
Please explain in detail any periods of unemployment:
Professional References:
Address:
Phone Number:
Professional References:
Address:
Phone Number:
Professional References:
Address:
Phone Number:
Education: School & Address | Did you graduate? | Type: Diploma/Degree/Certification | Dates attended
Why are you interested in this position?
Special skills and qualifications:
State any prior work experience you possess that relates directly to the position that you are applying for:
Upload your Resume:
Upload your Physical ID:
Upload 2 ID’s:
Upload your NJ home health aide license:
As the applicant, I hereby authorize Excellent Home Health Care may request and receive, within one year of the date of my signing this application, any and all pertinent information concerning my prior employment and its termination, including reasons for such termination from all prior employers. I understand that all references listed above may be contacted in addition to past employers and educational institutions. I give permission for Excellent Home Health Care to contact my current employer for a reference.
I certify that answers given are true. I give the agency authorization to complete an investigation of my statements and for 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 further understand that if I am hired, I can be terminated, with or without cause and with or without notice. I agree to have my picture taken for identification purposes and to submit to drug screening tests, upon request, with or without cause.
I understand that if I am applying for a DSP Position, I give the agency authorization to send me for fingerprinting (separate background check for the DHS), to conduct a central registry check, drug screening, and CARI check, to meet DHS standards.
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.
