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Employment Application

Please complete the following application for employment.

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? *
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:
*
Are You Related to Any Current Employee of Three Rivers? If So, In Which Facility Does This Relative Work?
*
Have You Ever Applied for Employment with Three Rivers Before? If so, When? *
Are You Presently Employed? *
If So, Where?
May We Contact Your Employer?
If So, Name and Telephone Number of Person to Contact:
Are You Available to Work: *
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? *
Do You Own a Dependable Vehicle with Insurance Coverage? *
Do You Possess a Valid Georgia Drivers License? *
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? *
What Was the Year of Original Issue?
Are There Current Restrictions to Your License?
If So, What Are the Restrictions?
If Applying For a Home Health Aide Position, Have You Been Certified?
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

Level Name Of School # Years Completed Graduated or GED Year Completed Area of Major or Specialized Training
High School N/A
Voc / Tech
College / University
Graduate / Prof

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

Employer (Most Recent)
Employed From

(Date: mm/dd/yy)
Employed Until

(Date: mm/dd/yy)
Beginning Salary: Ending Salary:
Employer 2
Employed From

(Date: mm/dd/yy)
Employed Until

(Date: mm/dd/yy)
Beginning Salary: Ending Salary:
Employer 3
Employed From

(Date: mm/dd/yy)
Employed Until

(Date: mm/dd/yy)
Beginning Salary: Ending Salary:

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

Type Reference Name Email Office Phone Home Phone
Work-Related
Work-Related
Personal
Personal
Additional Reference
Additional Reference

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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Testimonial

• The therapists were very knowledgeable about all aspects of physical therapy. Their knowledge shortened my time and length of

• Very cheerful, friendly, & helpful - both office & caregivers.

• Everyone was super nice.

• I can not say anything other than praise.

• Quite pleased with all care we received from the staff at Three Rivers. Excellent service! Skilled staff!

• I would like to say that Christine is the best PT! I love her she was so kind to me.

• Good work guys!

• They gave me very good care.

• I am a 2nd generation user of Three Rivers (my mother). It cannot be beat. Professional, caring & effective.

• I feel better after my treatments.

• I can say that Sonyia Walden & her staff have been very understanding. I've been the one in contact with her. Thanks.

• They were very helpful.

• Everyone was always kind and friendly.

• They all have been nice to me & caring.

• 3 Rivers has been very very flexible in dealing with me and my doctor's visits and emergency hospital visits.

• They were all very good & thoughtful of me.

• The care is excellent, however, all the new evaluations, etc and new paperwork rqmts have cut deeply into the time they can spend

• Both the physical and occupational therapists sent gave excellent care and were very pleasent.

• Debbie Moore is the best physical therapist I've ever had to help me.

• We have used other home health agencies but Three Rivers was by far the best!

• Outstanding

• I enjoyed having them all. I would like to give special thanks to Mrs. Trenis Jackson, RN; Mrs. Susan Bloodworth, LPN; Terri Burner, PT.

• I have had to have home health care from other home health care providers. Three Rivers is the agency I will always insist on.

• It is so nice to found Home Health Services, but to find yourself feeling you are leaving behind family and friends, is a nothe

• Very good, excelllent!

• The nurses are all friendly and come over about twice a week.

• They do an excellent job!

• I my self enjoy the services.

• Good, kind, people. They know what they are doing!

• They were excellent in the care I was given.

• Yes, I would recommend this agency to anyone. This agency took care of my husband for 13 years. They were wonderful!

• Everybody is very nice.

• I have nothing but praise for Three Rivers Health in Cochran, they are great!

• The best in every way.

• Yes, I was so surprised at the great care I was given by my nurses & each one was so nice, helpful and I have never been treated

• Very good.

• I especially like my PT "Aileen", she is disciplined, kind, starts & stops very timely, always pleasant & punctual, neat & efficient.

• We don't know what we would have done without your help. Thank you so much.

• They were very kind & helpful I have always recommended Three Rivers. My mother had Three Rivers for years she is 101 years old.

• EVERYTHING IS EXCELLENT!

• Lived up to expectations

• Excellent care!

• All the nurses wre so nice & sweet, it's like having my own chrildren around me.

• This is the second time we have used Three Rivers & have recommended it to others.

• I got wonderful care from 3 Rivers Home Health Services. I have absolutely no complaints. I could not have received any better care.

• Thank you.

• Pleased with the help I recieved.

• Excellent care!

• Their care for me is very good. They are very kind and efficient in this work.

• I mind them & they mind me - they are great!

• I loved seeing all the nurses that came. They were all extremely nice. I actually miss Susan Bloodworth.

• Very happy with all the staff that visited and helped me. My children could not have done better. Three Rivers Home Health Services

• Our family & myself have used Three Rivers before & have always been pleased. I worked with them as a C.N.A. over 9 yrs. & am very proud

• The people were always very kind & considerate of my needs.

• Everyone was very kind, caring - and listened to what I had to say - (excellent job) • Overall excellent!

• Good service.

• Very good treatment.

• All were very good at what they did.

• I love everyone that comes to help me.

• They are a very nice agency. They care about the people they take care of and will help you in any way they can. They have the

• The staff was OK, they just had problems getting answers from the Doctor they were contacting.

• Very professional!!

• We have used your home health care - 3 Rivers for several years now. Never had a complaint.

• Very good care & concerned.

• Nicole, the lady that provides 95% (other than nurse) of care is the best health provider anyone could ever have.

• The person who came to my home were wonderful to me.

• Wonderful, Great Nancy C. Brantley the best, sweet kind

• Care could not have been better. Debbie Moore PT is the greatest, as was Inkie OT.

• We have been very blessed with the help we have received from 3 Rivers.

• They are the best and if I get sick or hurt again I would call them for help again.

• Everything good.

• I am pleased with the care tha

• Continue to be a good agency. Thanks for a very great service. Sharonda Rawlings is a very good HHA.

• They were very friendly and they did their job well.

• I have been well pleased with Three Rivers Home Health Care. The nurses are very kind and considerate as well as thorough.

•Services were good. Providers were nice people.

• My care was the best!

• They are very good.



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