APPLICATION FOR EMPLOYMENT
Name
First
Middle
Last
ID Type Driver's License State ID Passport
Address(Required)
Are you 18 years of age or older(Required) Have you ever applied/worked for us before?(Required) Are you currently employed?(Required) Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (of citizenship or immigration status will be required upon employment)(Required) Are you available to work(Required) Shift Preferences(Required) Check days available for work(Required)
EDUCATION & OTHER INFORMATION Upload a certificate (if applicable)
LICENSE INFORMATION Have you ever had any disciplinary action against any of your licenses?(Required) Reason (s) for Leaving(Required)
May we contact this facility for a reference?(Required) May we contact this facility for a reference? May we contact this facility for a reference? Do you have any physical limitations that we should consider when placing you on an assignment?(Required) Have you ever been convicted of a felony for the last 5 years?(Required)
GENERAL INFORMATION 1. Have you ever pleaded guilty to or been convicted of a crime including convictions or guilty pleas in a court martial (excluding minor traffic violations for which a fine or forfeiture of $50 or less was imposed)?(Required) Please explain and provide the date, nature of the offense, the name and location of the court, the penalty imposed, if any, and the disposition of the case. Answering 'YES' will not affect your eligibility for hiring and a plea of guilty or a conviction does not necessarily eliminate the possibility of employment. Factors such as the date of the offense, your age at that time, nature of the violation, and rehabilitation will be taken into account (use additional paper if necessary).
2. Are there any criminal charges currently pending against you (e.g., are you out on bail on your own recognizance in connection with any criminal charges)?(Required) If yes, please explain (Answering 'YES' will not affect your eligibility for hiring):
3. Have you ever abused, neglected, sexually assaulted, exploited, or deprived any person? Have you ever subjected any person to serious injury as a result of intentional or grossly negligent misconduct?(Required) If yes, please explain (Answering 'YES' will not affect your eligibility for hiring):
4. Have you ever had any professional or occupational license or certification suspended or cancelled?(Required) If yes, please explain (Answering 'YES' will not affect your eligibility for hiring):
5. Have you ever had any disciplinary action taken against you by any licensing authority or professional or occupational association?(Required) If yes, please explain (Answering 'YES' will not affect your eligibility for hiring):
6. If your duties will involve driving, please answer the following: Have you ever had your driver’s license suspended or revoked? ((Required) If yes, please explain (Answering 'YES' will not affect your eligibility for hiring):
7. Please list any additional information you think we should consider in evaluating your application for employment (for example, hobbies, special skills and interests)
PERSONAL REFERENCES Speak 1 Read 1 Write 1 Speak 2 Read 2 Write 2 Speak 3 Read 3 Write 3 Job Knowledge Quality of Work Clinical Competency Attendance / Punctuality Dependability Attitude and Cooperation Personal Appearance Adaptability to Work Situations Trainings BEHAVIOR BASED COMPETENCIES
Organizational Behaviors
1. Change and Grow
2. Achievement
3. Respect & Respond
4. Energy & Initiative
5. Adaptability & flexibility
6. Superior skills
Organizational Competencies:
1. Educating clients and families & transferring knowledge
2. Identify & resolve problems
3. Anticipate & address client needs
4. Function as an effective team member
5. Acquire & apply superior skills to achieve quality outcomes
6. Respond to a changing set of circumstances
Client/Patient Specific Competencies:
1. Providing comfort to another in emotional/physical pain.
2. Responding to a crisis.
3. Providing a continuum of care approach.
Skills Based Competencies:
1. A graduate from an RN/LPN/CNA/HHA/DSP or PCA School at least 6 months of continuous work experience in a
healthcare setting within the last year or years.
2. A current license as a RN/LPN for the state in which the nurse practices and free from disciplinary action.
3 Successful completions of the Global Healthcare Agency tests for the specialty area(s) in which the nurse
practices with a score of 75% or greater.
4. Proof of fulfillment of the health screening criteria required by Global Healthcare Agency
And/or client facilities indicating the nurse is in good health and able to work without physical
limitations and is free from communicable disease.
5. A current CPR card, Hands on Training with Ink expiration date.
6. Completion and annually thereafter of the Global Healthcare Agency Employee Development and Self Study Inservice Programs.
7. Meet the minimum clinical criteria of Global Healthcare Agency Clinical skills checklist for those areas of clinical
expertise.
8. Full command, verbal and written, of the English language.
I have read the descriptions of my professional responsibilities as an employee of Global Healthcare Agency and
agrees to adhere to the standards described above.
HEPATITIS-B IMMUNIZATION RELEASE
Account Type Authorized Signature (Primary) Authorized Signature (Joint) 
