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PCA CNA
Office Staff LPN
RN
Part Time
Full Time
Temporary

EDUCATION AND TRAINING

Highschool


Vocational School


Undergraduate College


Graduate Professional


Other

CPR Alzheimer's
Stroke Oxygen
Hoyer Lift Feeding Tube
Parkinson's Cancer
Hospice Slide Board
Catheter

LICENSURE


Yes No
Yes No
Yes No

GENERAL INFORMATION

Advertisement Job Search Site
Friend/Relative Website
Employment Agency General Inquiry
HAHHC Employee Other
Yes No
Yes No
Yes No
Yes No

EMPLOYMENT HISTORY

List the last five work experience beginning with the present or most recent job.
Yes No

Yes No

Yes No

REFERENCES

List three (3) professional references we may contact. Provide name, address, telephone number and email.

AGREEMENT
(Please read the following statement carefully.) I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I authorize all persons listed about (and on the accompanying resume, if any) to give HAHHCINC any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise and release all parties, such person and HAHHCINC from liability for any damage that may result from furnishing same to HAHHCINC. I understand that HAHHCINC and its client have agreed that HAHHCINC will provide workers' compensation insurance coverage for it employees. In the event of an injury in the workplace, I agree that my sole remedy lies in coverage under HAHHCINC workers' compensation insurance policy. If employed by HAHHCINC, I agree to conform to the rules and regulations of HAHHCINC and its client company to which I am assigned. I further understand that my employment is "at-will" and can be terminated, with or without cause or notice, at any times, at the discretion of either HAHHCINC or myself. I further understand that no manager or representative of HAHHCINC or its client company, to which I am assigned, other than the CEO of HAHHCINC, has any authority to enter into any agreement, oral or written, for employment for any specified period time or to make any assurance or promise of combined employment. I understand and agree that I may be required to take a drug and alcohol-screening test. I hereby give my voluntary consent for a blood and/or urine sample to be collected from me and submitted for testing. I also consent to the release of the test result to HAHHCINC for its use. I understand that any positive drug or alcohol result may preclude my employment.

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