* = Required Information

APPLICATION FOR EMPLOYMENT
APPLICANTS MAY BE TESTED FOR ILLEGAL DRUGS
All applicants must be 18 or older to submit a job application.
Date
YesNo
No Pref Mon
Tue Wed
Thur Fri
Sat Sun
Full-Time Only
Part-Time Only
Full-or-Part-Time
YesNo
Date of last physical exam *
TYPE OF SCHOOL NAME OF SCHOOL LOCATION
(Complete mailing address)
NUMBER OF YEARS COMPLETED MAJOR OR DEGREE
High School
College
Bus or Trade School
Professional School
Certificates Acquired
NoYes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
PREVIOUS PROFESSIONAL EXPERIENCE/KNOWLEDGE
Medicare Certified Education JCAHO Ambulatory Care
JCAHO Homecare/Hospice State Regulatory Compliance PI/CQI/QA
COP's Homecare Licensed/Private Duty Strategic Planning
JCAHO Nursing Home CHAP JCAHO Pharmacy
JCAHO DME COP's Hospice HCFA Compliance
Corporate Compliance JCAHO Hospital UR/Record Audits
FOREIGN LANGUAGES
MILITARY
Yes No
Yes No
WORK EXPERIENCE
Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Reason for leaving *(Be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company *

Reason for leaving *(Be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company *
DRIVERS AND NON-DRIVERS
YesNo
Operator
Chauffeur
Commercial(CDL)
FOR NURSES AND PROFESSIONAL LICENSE HOLDERS

Yes No
State any additional information that you feel may be helpful to us in considering your application
PLEASE READ CAREFULLY
APPLICATION FORM WAIVER
In exchange for the consideration of my job application by Sophie's Health Care Services, Inc. (hereinafter called 'the Company.). I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either In the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment or to confer any right to remain an employee of Sophie's Health Care Services, Inc., or otherwise to change in any respect the employment-at-win relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Administrator of the Company. Both the undersigned and Sophie's Health Care Services, inc. may end the employment relationship at any time, without specified notice or reason. It employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shalt be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
 
 
This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications

Thank you for completing this application form and for your interest in our business.