FOREMOST HOME CARE EMPLOYMENT APPLICATION
PRINT THIS FORM AND FAX TO: 212-564-7517

PLEASE PRINT ALL INFORMATION CLEARLY
Position applying for: RN [  ]   LPN [  ]   HHA [  ]   PCA [  ]  
Certification: PCA [  ]   HHA [  ]   Professional License: LPN [  ]   RN [  ]  

Certificate/License #: ____________________________
State: ________
Expiration Date: ________

Name: __________________________________________________________________

Telephone: (        ) _____________________ Social Security #: ___________________

Street: __________________________________________________________________

City: ______________________   State: ________   Zip Code: ____________________

Are you 18 years of age or older? YES [  ]    NO [   ]
Are you a U.S citizen? YES [  ]    NO [   ]
Are you a legal resident? YES [  ]    NO [   ]
If not, do you have the legal right to work in the U.S? YES [  ]    NO [   ]

Previous Employment (Most Recent Position First)
 
From To Name & Address of Previous Employer or Reference Job Description Pay Rate Reason for Leaving




































Education
 
  Name of School Did you graduate? Subject Degree
High School







College







Nursing School







Aide Training







Other







Have you ever been arrested? YES [  ]    NO [   ]
Have you ever been convicted of a crime? YES [  ]    NO [   ]
Will you work? Days [  ]    Evenings [   ]    Nights [   ]    Weekends [   ]
 
Area(s) preferred: ___________________________________________
 
Do you drive? YES [  ]    NO [   ] Own a car? YES [  ]    NO [   ]
Do you have a valid New York State Driver's License? YES [  ]    NO [   ]
Do you mind pets? YES [  ]    NO [   ] Allergies? YES [  ]    NO [   ]
Work with children? YES [  ]    NO [   ] Any age? YES [  ]    NO [   ]

Please Read and Sign
I affirm to the best of my knowledge , the information given on this application is true and may be verified.

I hereby authorize this company, and also authorize and request each former employer and person, firm or corporation given as a reference, to answer all questions that may be asked, and give all information that may be sought in connection with this application or concurring me or my work, habits, character or skill or my action in any transaction. If employed, I agree that if at any time I shall make claims against the company for persaonl injuries, upon written request I will submit myself to an examination by a physician or physicians of the company's selection as often as may be requested.

Signature: ______________________________________ Date: __________________

FOREMOST HOME CARE is an Equal Opportunity Employer and complies with Federal, State and Local laws which prohibit direct discrimination in employment because of race, color, creed, age, sex, martial status, national origin or disability.