Name *
Email Address *
Date *
Phone *
Social security # *
Address,City,Zip *
If applicable, military status:
If hired under 18 can you furnish a work permit? *
Are you legally entitled to work in the US? *
Have you ever been employed by Precious Gems Homecare or any of its affiliates? *
List all relatives employed by Precious Gems Homecare or its affiliates and Relationship:
Position Applied For *
Date *
Status and Schedule Desired
Shift Availability
How did you hear about this organization?
If you selected Other please explain or enter the name and number of the person who referred you:
High School Graduate or General Education (GED) *
If no list the highest grade completed: *
College, Business School, Military *
Name and Location *
Dates Attended Month / Year *
Credits Earned *
Graduate *
Degree And Year *
Major or Subject *
Foreign Language 1:
Sign Language
Skills:
Other Skills :
Do you authorize us to contact your past and present employers for references? *
If no, please explain: *
List your complete employment history starting with your present employer first and working backward, (including volunteer experience) *
Employer: *
Address: *
Job Title: *
Supervisor’s Name: Phone: *
From: *
To: *
Reason for Leaving: *
Job Duties: *
Phone: *
Employer:
Address:
Job Title:
Supervisor’s Name: Phone:
From:
To:
Reason for Leaving:
Job Duties:
Phone:
ADDITIONAL INFORMATION SHEET (if necessary, please use this sheet)
PLEASE READ CAREFULLY: I certify that I am not currently excluded, suspended, debarred, or otherwise ineligible to participate in federal or state health care programs (included but not limited to, Medicare and Medicaid). I further acknowledge that if I have been found to have violated the law or receive notification of exclusion from Medicare, Medicaid or any other governmental program, I am to report such, in writing to the Compliance Officer within (2) business days. I certify that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information called for on this application will constitute grounds for denial or immediate dismissal from employment. I authorize all persons, schools, employers and other organizations mentioned in this application to provide Precious Gems Homecare with any and all information requested by the Precious Gems Homecare to my qualifications for employment. I hereby voluntarily release Precious Gems Homecare and any other persons or entities from any and all liability related to the provision of such information. I understand that if a job offer is made, employment will be contingent upon satisfactory results of: references checks; verification of license/registration/certification and/or medical staff privileges (if required for a position): medical screening examination which includes testing for substance abuse; background check requiring a completion of a consent and disclosure form: fingerprinting (if required): and attendance at new employee orientation. If during the course of my employment any information provided in the application changes, I have an affirmative obligation to report these changes to the Human Resources Department. Failure to report these changes may jeopardize my employment and may be the basis for disciplinary action up to and including termination. In addition, I will be required to provide satisfactory documentation of my U.S. Citizenship or authorization to work in the U.S. within 72 hours of the commencement of my employment. I understand that nothing in this application for employment is intended or should be construed as an offer agreement or contract of employments. I understand that my employment with Precious Gems Homecare is dependent upon satisfactory completion of my required probationary period. In the event that I am employed by Precious Gems Homecare, I agree to comply with all of its employment policies, rules and regulations, including its Corporate Compliance Program. Precious Gems Homecare reserves the right to change or amend policies. (Write Initials)
Print Name: *
Applicant Signature *
By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. *
Date *
Federal and New Jersey Law prohibits discrimination in employment on the basis of race, color, creed, national origin, sex, age, marital status, disability, sexual orientation, citizenship, veteran status or any other characteristic prohibited by law
I, hereby authorize Precious Gems Homecare to request and receive from all prior employers within one year of the date of this application, and all pertinent information concerning my prior employment and its termination, including the reason for such termination, and I release from liabilities or responsibilities any person, companies, or institutions supplying such information.(Write your name in the field below) *
Desired Salary (Optional)
Upload Your CV/Resume (PDF Only) *
