Employment Application - R&R Healthcare

R & R Health Care Services LLC is an equal opportunity employer. The agency does not discriminate in employment concerning race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status, or unfavorable discharge from military service or any other characteristic protected by law.

Disqualifying Offenses Attestation

I attest to the below statement

By checking below, you are attesting to having no previous convictions for the disqualifying offenses listed in OAC 5123:2-2-02 and attest you will notify R & R Health Care LLC within 14 days if ever charged with or plead guilty to a disqualifying offense as listed in OAC 5123:2-2-02.

PERSONAL INFORMATION

Incomplete information could disqualify you from further consideration. Please complete all fields.

Full Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Home Phone

Mobile Phone

Are you eligible to work in the U.S.?

Yes
No

Are you at least 18 years or older?

Yes
No

If no, you may be required to provide authorization to work.

Have you ever been terminated from employment or asked to resign by an employer?

Yes
No

If yes, please provide company names and details

EMPLOYMENT DESIRED

Date you can start

Hourly rate/Salary desired

Position desired

Are you currently employed?

Yes
No

If so, may we inquire with your present employer?

Yes
No

Can you perform the job's essential functions for which you are applying, with or without reasonable accommodation?

Yes
No

REFERRAL SOURCE

How did you hear about us?

Have you ever worked for R & R Health Care before?

Yes
No

If yes, please explain

Do you know anyone who works for our company?

Yes
No

If yes, who?

EDUCATION

List your educational background below. Leave blank if not applicable.

High School - Name and Location

High School - Degree Received

High School - Subjects Studied / Major

College or University - Name and Location

College or University - Degree Received

College or University - Subjects Studied / Major

Trade, Business or Correspondence School - Name and Location

Trade, Business or Correspondence School - Degree Received

Trade, Business or Correspondence School - Subjects Studied / Major

EMPLOYMENT HISTORY

Include your last seven (7) years of employment history, including periods of unemployment, starting with the most recent and working backward in time. Incomplete information could disqualify you from further consideration.

Most Recent Employer

Employer 1 - From Date

Employer 1 - To Date

Leave blank if current

Employer 1 - Employer Name

Employer 1 - Telephone

Employer 1 - Job Title

Employer 1 - Address

Employer 1 - Immediate Supervisor and Title

Employer 1 - Nature of Work and Responsibilities

Employer 1 - Reason for Leaving

Previous Employer

Employer 2 - From Date

Employer 2 - To Date

Employer 2 - Employer Name

Employer 2 - Telephone

Employer 2 - Job Title

Employer 2 - Address

Employer 2 - Immediate Supervisor and Title

Employer 2 - Nature of Work and Responsibilities

Employer 2 - Reason for Leaving

Previous Employer

Employer 3 - From Date

Employer 3 - To Date

Employer 3 - Employer Name

Employer 3 - Telephone

Employer 3 - Job Title

Employer 3 - Address

Employer 3 - Immediate Supervisor and Title

Employer 3 - Nature of Work and Responsibilities

Employer 3 - Reason for Leaving

Previous Employer

Employer 4 - From Date

Employer 4 - To Date

Employer 4 - Employer Name

Employer 4 - Telephone

Employer 4 - Job Title

Employer 4 - Address

Employer 4 - Immediate Supervisor and Title

Employer 4 - Nature of Work and Responsibilities

Employer 4 - Reason for Leaving

SPECIAL SKILLS

Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, explain.

REFERENCES

Give the names of three persons not related to you, whom you have known at least three (3) years.

Reference 1

Reference 1 - Name

Reference 1 - Address, Phone, Email

Reference 1 - Company

Reference 1 - Years Acquainted

Telephone perform SIGNATURE

Reference 2

Reference 2 - Name

Reference 2 - Address, Phone, Email

Reference 2 - Company

Reference 2 - Years Acquainted

Reference 3

Reference 3 - Name

Reference 3 - Address, Phone, Email

Reference 3 - Company

Reference 3 - Years Acquainted

EMERGENCY CONTACT

Emergency Contact - Name

First

Last

Emergency Contact - Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact - Phone Number

AVAILABILITY

Check all shifts you are available to work.

Monday - Available Shifts

1st Shift
2nd Shift
3rd Shift
Not Available

Tuesday - Available Shifts

1st Shift
2nd Shift
3rd Shift
Not Available

Wednesday - Available Shifts

1st Shift
2nd Shift
3rd Shift
Not Available

Thursday - Available Shifts

1st Shift
2nd Shift
3rd Shift
Not Available

Friday - Available Shifts

1st Shift
2nd Shift
3rd Shift
Not Available

Saturday - Available Shifts

1st Shift
2nd Shift
3rd Shift
Not Available

Sunday - Available Shifts

1st Shift
2nd Shift
3rd Shift
Not Available

Can you work any shift?

Yes
No

If no, please explain

Can you work overtime, including weekends?

Yes
No

ATTESTATION AND SIGNATURE

Please read carefully before signing.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for R & R Health Care LLC to hire me. If I am hired, I understand that either R & R Health Care LLC or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of R & R Health Care LLC has the authority to make any assurance to the contrary.

I attest with my signature below that I have given R & R Health Care LLC accurate and complete information on this application. No requested information has been concealed. I authorize R & R Health Care LLC to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

Agreement

I have read and agree to the above statement

Type Your Full Name as Signature

Date

THIS APPLICATION IS VALID ONLY FOR 60 DAYS FROM THE DATE ABOVE.