PART 1 - GENERAL

Position Applied For: *

Personal Information:
Name:	* * (Last, First, Middle Initial)
Address:	*
	*
	*
	*
Phone:	*
Email:	*
Additional Information:
	Any Other Name(s) Previously Known By:
	Are You Legally Eligible to Work in the United States? *---YesNo
	Social Security Number: *
	Have You Ever Been Convicted by a Court of Law of any Offense, Other than a Minor Traffic Violation? If So, Provide the Specifics: *---YesNo ---YesNo
	Are You Related to Any Current Employee of Three Rivers? If So, In Which Facility Does This Relative Work? *---YesNo
	Have You Ever Applied for Employment with Three Rivers Before? If so, When? *---YesNo
	Are You Presently Employed? *---YesNo
	If So, Where? May We Contact Your Employer? ---YesNo If So, Name and Telephone Number of Person to Contact:
	Are You Available to Work: *---Full-timePart-timeAs needed
	If Offered a Job, What Length of Notice Will You Give Your Employer?
	All Patient Care, Supervisory and Management Positions Require Travel. If You Are Applying For This Type Position, Can You Travel? *---YesNo
	Do You Own a Dependable Vehicle with Insurance Coverage? *---yesno
	Do You Possess a Valid Georgia Drivers License? *---yesno
	If You Are Applying for a Position Designated To Be Filled by a Health Care Professional (i.e., Nurses, Therapists), Are You Licensed by a Professional Board of Georgia? *---yesno
	What Was the Year of Original Issue? Are There Current Restrictions to Your License? ---yesno If So, What Are the Restrictions?
	If Applying For a Home Health Aide Position, Have You Been Certified? ---yesno
	Please Furnish Copies of Nursing Certificates, Licenses or Diplomas Relative to the Position For Which You Are Applying. If Furnishing Multiple Documents, Please Compress or Zip, And Upload the Single, Compressed File:

PART 2 - EDUCATION

Honors or Recognition Received in Any of the Above:

Give a Brief Description of Any Specialized Training in Addition to the Above That Could Aid in Your Job Effectiveness (Including Dates, Duration and Location):

PART 3 - EMPLOYMENT

PART 4 - ACTIVITIES

List Civic, Community, Professional, Trade, or Other Organizations in Which You Are a Member, Including Any Offices or Positions of Leadership Which You Have Held:

PART V - REFERENCES

PART 6 - SUMMARY

In Your Own Words, Please State Why You Would Like to be Employed by This Company:

NOTE: If you are tentatively offered a position with Three Rivers Home Health, you must satisfactorily complete a pre-employment health examination. As part of the selection process, you may be required to test for drugs and alcohol. Applicants who test positive for drugs or alcohol may not be eligible for employment. Applicants who refuse to submit to required drug and alcohol testing may not be considered for employment. A copy of your motor vehicle report will be requested from the appropriate agencies in various states, including the Georgia Department of Public Safety. Your privately owned vehicle, which you will be driving if employed, must pass a basic safety inspection. Also, Three Rivers may screen your financial and criminal history. As an employee, you may be required to submit to random drug screening at any time, at Three Rivers’ discretion.

APPLICANT’S STATEMENT: I certify the information herein is voluntarily provided and true and complete to the best of my knowledge. Also, I authorize investigation of all statements contained herein as may be necessary regarding consideration for employment. Further, I understand that any false statements or omissions may disqualify me from consideration and may be considered justification for dismissal if discovered at a later date.

SIGNATURE STATEMENT: By entering my name and the date below, I acknowledge that I am electronically signing this document, and I further acknowledge that I agree to all the terms and conditions set forth herein, and certify that all information supplied by me is true and correct.

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