Application for Employment

You must complete and submit an application for employment to be considered. * All fields marked in bold and with an asterisk are required.

The Application for Employment (PDF) is also available as a download.

If employed the following must be provided to Nightingale's Nursing & Attendants

1. Drivers License
2. Social Security Card
3. Proof of car insurance
4. 10 Year Driving Record
5. Recent PPD (TB test record)
6. Any Certificates (CPR, etc)
7. Nursing License (if applicable)
8. SLED background check
9. Verifiable character references

Personal Information

Last Name *
Maiden Name
First Name *
Email Address *
Street Address *
City *
State * Zip *
Mailing Address *
Position Applying For *
Telephone *
Cell Phone
Emergency Phone No. *
Salary Required (per hour) * $
Current Employer
Current Position
Current Salary $
Referred By *
Ever applied here before? If yes, when?
Special Training
Special Training (Where?)
Special Training (When?)

Education

High School * Location * Years Attended * Did you graduate?
Yes
College Location Years Attended Did you graduate?
Yes
Vocational/Adult Education Location Years Attended Did you graduate?
Yes

General Information

Please provide all information or formal training which you believe has prepared you for this line of work (include work with the elderly or the infirm), length of time and situation. *

Former Employer (List last one first)

Dates (MM/DD/YY) From To / Present
Employer Name
Employer Address
Reference Name
Reference Telephone
Salary $
Position
Reason for leaving

Former Employer (2)

Dates (MM/DD/YY From To
Employer Name
Employer Address
Reference Name
Reference Telephone
Salary $
Position
Reason for leaving

Former Employer (3)

Dates (MM/DD/YY From To
Employer Name
Employer Address
Reference Name
Reference Telephone
Salary $
Position
Reason for leaving

Character References (Do not use family members)

Name * Phone No.(s) * Years Known* How Acquainted*

Other Information

Reasons you want to work for Nightingale's Nursing & Attendants *
How did you hear about Nightingale's Nursing & Attendants? *
List your personal goals: *

Telephone, transportation & driver's license

I certify that I have dependable transportation * Yes No
I certify that I have access to a telephone for easy communication * Yes No
I certify that I have a valid driver's license * Yes No
I certify that I have an insured vehicle * Yes No

Criminal Record

Have you been convicted of a crime within the last 10 years? * Yes No
If yes, please describe
Any felonies? Yes No

Miscellaneous

I understand that my job is not complete until I turn in my Care Plan/Time Sheet and agree to do so prior to receiving payment from Nightingale's * Yes No
I understand that dependability is extremely important to home care. I will notify the office at least 3 days prior to requesting time off. * Yes No
I understand that clients have the option of refusing my services at any time and this may be no fault of Nightingale’s. * Yes No
I understand that I will be required to participate in 10 hours of in service training annually (6 required for nurses) and will attend mandatory meetings. * Yes No
I certify that I have no prior mental or physical impairments that will affect or limit my work capabilities for any assignments. * Yes No
I certify that if I have ever had a workman’s compensation case against an employer for personal injury that I am 100% cleared by my physician to return to work. * Yes No
I agree to accept responsibility for working safely. * Yes No
I agree to never accept money or tips of any kind from a client without Nightingale’s permission. * Yes No
I understand that asking to borrow money from a client is grounds for immediate termination. * Yes No
I understand that I cannot work privately or in any capacity other than an employee of Nightingale’s with clients assigned to me by Nightingal's. * Yes No

Counties

Nightingale’s provides services to the following Counties (Please select all of those in which you are willing to work):

Tip: To select multiple locations, hold down the Ctrl key while clicking each county.
I am willing to work within a 50 mile radius of the selected counties. Yes No

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of my background through SLED checks and all other information provided and release Nightingale’s from all liability from any damage that may result from using such information. I also understand and agree that no representative of Nightingale’s has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing, unless in writing and signed by an authorized Nightingale’s representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans With Disabilities Act (ADA) and other relevant federal and state laws. *
I Agree I Do Not Agree

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