Personal Data

Emergency Contact Information

Contact 1

Education and Training

Training 1

Job Information

  • RN
  • LP/VN
  • CNA
  • PCA
  • Clerical
  • Other
  • Hospital
  • Hospice
  • Nursing Home
  • Rehab
  • Private Duty
  • Assisted Living / Residential Treatment
  • Spanish
  • French
  • German
  • Other
  • Full-time
  • Part-time
  • Contract
  • Travel
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday
  • Holidays available to work:

License Detail

  • Yes No

License 1


  • ACLS
  • BCLS
  • CPR
  • PALS
  • Other
  • IV
  • NALS

Work Experience

List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Add more if necessary.

Experience 1

Work Related Information

Please list any other work related information you think would be helpful to us in considering you for employment, such as specialized training, certifications, additional work experience, etc.


1 Have you been convicted (as guilty or not innocent, either under civil or military law, or a determination of abuse or neglect founded against you) of a misdemeanor, a felony or ANY offense involving moral turpitude, the sexual molestation, physical abuse, neglect, or rape of a child, or any like offense against an adult? (if YES, provide explanation below)
2 Are any criminal or non-civil charges pending against you? (if YES, provide explanation below)
3 Have you ever been fired or asked to resign from any job? (if YES, specify employer, date and reason below)
4 Do you have a valid Drivers License? (if YES, please list state, number, expiration date and type/endorsement)
5 Have you had any motor vehicle accidents in the last three years?
6 Has your driver's license ever been suspended, revoked, denied or canceled?
7 Have you ever been employed here before?
8 Are you legally eligible for employment in this country?
9 Are you 18 years of age or older?


Name Relation Contact

ACKNOWLEDGEMENT (Please read carefully and sign)

I understand that I must report all accidents to my immediate supervisor and to Love & Care Home Healthcare Agency, LLC - - No MATTER HOW SLIGHT.
I also understand that I must wear all required personal protection equipment (PPE).The penalty for not wearing PPE is disciplinary action, up to and including termination.

ACKNOWLEDGMENT (Please read carefully and sign)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give Love & Care Home Healthcare Agency, LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Love & Care Home Healthcare Agency, LLC with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Love & Care Home Healthcare Agency, LLC may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Love & Care Home Healthcare Agency, LLC, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Love & Care Home Healthcare Agency, LLC, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Love & Care Home Healthcare Agency, LLC or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Love & Care Home Healthcare Agency, LLC, at any time, can constitute a contract of employment. No representative or agent of Love & Care Home Healthcare Agency, LLC, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that Love & Care Home Healthcare Agency, LLC is not involved in the day-to-day supervision or decision concerning client care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Love & Care Home Healthcare Agency, LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.