Applicant and Position Information
Full Legal Name:
Preferred Name:
Address:
City:
State:
ZIP:
Phone
Email:
Position Sought:
Work Location:
Date Available:
Date of Application:
Desired Pay Rate: $
Position pay range and benefits provided to applicant separately on:
By
Education and Professional Qualifications
School or Program
Degree or Credential
Completion Date
School or program
Degree or credential
Completion date
School or program
Degree or credential
Completion date
School or program
Degree or credential
Completion date
Licenses or certifications relevant to role, including number, state, and expiration:
Relevant training, EHR systems, languages, and professional skills:
Employment Experience
List the three most recent relevant employers. Do not include compensation or wage history.
Organization:
Job Title:
Supervisor and Contact:
Dates Employed:
Main Duties:
Reason For Leaving:
Organization:
Job Title:
Supervisor and Contact:
Dates Employed:
Main Duties:
Reason For Leaving:
Organization:
Job Title:
Supervisor and Contact:
Dates Employed:
Main Duties:
Reason For Leaving:
Professional References
List three people familiar with your work, excluding relatives unless they supervised your work.
Name and Title
Organization and Relationship
Phone and Email
Name and title
Organization and relationship
Phone and email
Name and title
Organization and relationship
Phone and email
Applicant Certification and Screening
I certify that the information in this application is true and complete to the best of my knowledge. I understand that material omissions or false statements may result in withdrawal of an offer or termination of employment. I authorize Golden Hands Homecare Inc. to contact listed references and verify qualifications, subject to applicable law. Any background, exclusion, license, or other screening requiring a separate authorization will be handled separately. I understand that an offer may be contingent on satisfactory screening and verification.
Date:
Maryland Polygraph Notice
UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH EXAMINATION OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
I acknowledge receipt of the notice above.
Date:
Confidentiality and Non Disclosure Agreement
If hired, I will protect confidential information obtained through my work, including client and family information, protected health information, personnel records, business records, credentials, and nonpublic operational information. I will access, use, and disclose such information only as needed for authorized duties and as permitted by law and organizational policy. I will not discuss clients in public or through unapproved channels, share passwords, remove records without authorization, or use information for personal purposes.
I will follow Golden Hands Homecare Inc. privacy and security policies and applicable HIPAA requirements; promptly report suspected privacy or security incidents; return organizational records and property when requested or upon separation; and continue to protect confidential information after my work ends, except where disclosure is required or protected by law. This agreement does not restrict lawful reporting to government agencies, discussion of wages or working conditions, or other legally protected activity.
Date:
Employment Terms Acknowledgment
I understand that this application and confidentiality acknowledgment do not create an employment contract for a fixed term or guarantee employment. If I am hired as an employee, my employment is at will to the extent permitted by law: I or Golden Hands Homecare Inc. may end it at any time, with or without cause or advance notice, subject to applicable law. My duties, schedule, compensation, regular paydays, and leave benefits will be set out in a separate written offer or hiring notice and applicable policies. Any independent contractor engagement requires a separate signed agreement specifying scope, payment, and status; this application alone is not such an agreement.
Date:
Employer use only: Interview date
Verified by
Disposition
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