* = Required Information

Today's Date *
Last Name *
First Name *
Phone *
Alternate Phone *
Email *
Current Address *
City
Zip
Emergency Contact
Phone and Relationship
Position Applying for
Desired Salary /Per Visit
AVAILABILITY
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
AM
PM
EDUCATION
Type of School Name of School Location Major/Degree Awarded
High School
College(s)
Business Technical or
Certificate Program(s)
Do you currently speak any other languages besides English?
YesNo
If Yes, what language and how fluent?
Have you ever been convicted of an offense, crime or felony other than a minor traffic violation? (Do not include convictions while a minor and/or convictions sealed by Court order)
YesNo
If yes, please state the nature of the offense(s), date(s), city, state and disposition. A conviction record does not automatically bar you from employment with Kingsway Home Health Services, Inc. The nature, recent and disposition of an offense will be considered only as it relates to the job for which you are applying
Have you been terminated from a previous employment? YesNo
Have you been involved in professional regulation disciplinary proceedings? YesNo
Have you been ask not to return to a health care facility through another agency? YesNo
WORK EXPERIENCE

Please account for ALL work experience within the last 5 years beginning with your most recent position. If self employed at any time, please note and elaborate.
Name of Current Employer
Address
City
State
Zip
Phone Number
Supervisor
Salary Start/Rate of pay per hour:
Pay or Salary Start
Pay or Salary End
Last Job Title
Describe Your Duties
Reason for Leaving
May we contact this employer? YesNo

Previous Employer
Address
City
State
Zip
Phone Number
Supervisor
Salary Start/Rate of pay per hour:
Pay or Salary Start
Pay or Salary End
Last Job Title
Describe Your Duties
Reason for Leaving
May we contact this employer? YesNo

Previous Employer
Address
City
State
Zip
Phone Number
Supervisor
Salary Start/Rate of pay per hour:
Pay or Salary Start
Pay or Salary End
Last Job Title
Describe Your Duties
Reason for Leaving
May we contact this employer? YesNo

Previous Employer
Address
City
State
Zip
Phone Number
Supervisor
Salary Start/Rate of pay per hour:
Pay or Salary Start
Pay or Salary End
Last Job Title
Describe Your Duties
Reason for Leaving
May we contact this employer? YesNo
MILITARY
Have you ever been in the Armed Forces? YesNo
Are you a current member of the National Guard? YesNo
Specialty
Date Entered Date Discharged
Do you have a valid driver's license? YesNo
REFERENCES
Please list three references other than your relatives:
Name How long have you known this person?
Profession Phone Number
Address

Name How long have you known this person?
Profession Phone Number
Address

Name How long have you known this person?
Profession Phone Number
Address
PLEASE READ CAREFULLY BEFORE SIGNING
* I understand that my signature below and the information provided establish no obligation on the part of Kingsway Home Health Services, Inc. to employ me. There has been no implied guarantee that my completion of this application will result in my employment. I authorize Kingsway Home Health Services, Inc. or their agent to make any investigation and receive information relevant to my suitability for employment. I agree that if any misrepresentation has been made by me or the results of such investigations are not satisfactory in the judgment of Kingsway Home Health Services, Inc., any offer of employment may be withdrawn or my employment terminated immediately without any obligation or liability to me other than payment at the rate agreed upon for services actually rendered. I further authorize any of my references, employers, schools or military authorities to furnish information requested by Advantage Home Health Plus, Inc and thereby release all such information to Kingsway Home Health Services, Inc.