Employment Application Form Name* First Middle Last Date* MM slash DD slash YYYY Telephone #:*Email Current Address* Street Address City State ZIP Code Position Applying For?*RN/LPNRegistered Home Health Aide or CNACompanion/Caregiver (no experience)Companion/Caregiver (prior experience)Which Adaptive Indiana location are you applying for?Bedford, INIndy North OfficeBloomington, INColumbus, INEvansville, INFort Wayne, INGreenwood, INJasper, INJeffersonville, INKokomo, INLafayette, INMuncie, INNew Albany, INNewburgh, INDesired Hourly Rate*$1$2$3$4$5$6$7$8$9$10$11$12$13$14$15$16$17$18$19$20$21$22$23$24$25$26$27$28$29$30$31$32$33$34$35$36$37$38$39$40$41$42$43$44$45$46$47$48$49$50$51$52$53$54$55$56$57$58$59$60$61$62$63$64$65$66$67$68$69$70$71$72$73$74$75$76$77$78$79$80$81$82$83$84$85$86$87$88$89$90$91$92$93$94$95$96$97$98$99$100Employment desired:* Full Time Part Time Days Nights Hours Per Week Preferred: Have you been previously employed by Adaptive?* Yes No If YES, when? Are you at least 18 years old?* Yes No Are you a US Citizen, or do you have the legal right to remain and work permanently in the US?* Yes No Do you have adequate means of transportation to get to and from work each day?* Yes No Can you provide a negative TB test in the last 12 months?* Yes No Have you had a Health Assessment/Physical completed by a doctor within the last six months?* Yes No Professional License/Certifications currently held: HHA CNA LPN RN Companion / Homemaker Have you ever had any license revoked, suspended, limited, or not renewed in any state?* Yes No If YES, describe in full:Have you ever been convicted of a crime?* Yes No If YES, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment):Did you graduate from high school or obtain your GED?* Yes No Employment HistoryUpload Resume:Accepted file types: doc, pdf, rtf, html, txt, odf, docx, Max. file size: 300 MB.Name of Company* City of Company* State of Company*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPosition Held/Description of type of work*Previous Pay$1$2$3$4$5$6$7$8$9$10$11$12$13$14$15$16$17$18$19$20$21$22$23$24$25$26$27$28$29$30$31$32$33$34$35$36$37$38$39$40$41$42$43$44$45$46$47$48$49$50$51$52$53$54$55$56$57$58$59$60$61$62$63$64$65$66$67$68$69$70$71$72$73$74$75$76$77$78$79$80$81$82$83$84$85$86$87$88$89$90$91$92$93$94$95$96$97$98$99$100Reason for Leaving* Still Employed Resignation Termination Lay Off **Adaptive provides equal employment opportunities without regard to race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability. I certify that the information in this application is true and complete for all practical purposes. Should a position be offered and later it is found that any of this information is untrue, incomplete, or misrepresented, I understand and agree that the Adaptive has the right to end my employment. I voluntarily give Adaptive the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9) and within 3 days show satisfactory evidence of identity and eligibility for employment.Terms and Conditions:* I understand and acknowledge the terms and conditions as stated above Signature*Today's Date:* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
