* = Required Information
Full-Time Part-Time Temporary
Phone Email

No Preference
D E N
D E N
D E N
D E N
D E N
D E N
D E N
MILITARY
Yes No
ADMINISTRATIVE SKILLS
Yes No
Yes No
Yes No
PEDIATRIC WORK EXPERIENCE ONLY
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.

PEDIATRIC WORK EXPERIENCE ONLY

PEDIATRIC WORK EXPERIENCE ONLY

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.

OTHER WORK EXPERIENCE

OTHER WORK EXPERIENCE
Yes No
Yes No
PERSONAL REFERENCES
Please list two references other than relatives or previous employers

EDUCATION
Please indicate the highest education you have achieved
Some High School High School Diploma/G.E.D Some College Associate's Degree
Bachelor's Degree Advanced Degree Master's Degree
Yes No

Yes No

Yes No

Yes No
AFFIDAVIT
I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am contracted, any false misleading or otherwise incorrect statements made on this application from or during any interviews may be grounds for my immediate discharge.

I herby authorize the Company to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications, and I give my full and complete consent to their individuals for defamation, invasion of privacy or any other reason because of their statements.

I agree that, if I am employed, I will abide by all the rules and regulations of the company. I understand that the taking of drug and alcohol test, when given pursuant to company policy, are a condition of continued contract and refusal to take such tests when asked will be grounds for immediate termination of my contract. I further understand that nobody in the Company is authorized to enter into any written or verbal contracts with me for any definite period of time without the express written consent of the President of the Company. I also understand that my contract is "at will” and may be terminated by myself or by the company at any time for any reason or no reason at all, with or without prior notice.
Acknowledgement Agreement
I aggree that I will not for a period of 365 days after I cease contracting with Aadvance Home Health Services seek employment with or provide services to any client (patient or family) to whom I have been assigned to work by Aadvance Home Health Services directly as an employee or independent contractor of another agency. Unless I receive written permission from Aadvance Home Health Services. I understand and agree that if I violate this agreement, Aadvance Home Health Services shall obtain an Injunction restraining me from any further violation. In addition to compensatory damages at Aadvance Home Health Services election, I agree to pay Aadvance Home Health Services, 10% of my most recent hourly rate as Aadvance Home Health Services contract, multiplied by 200 hours as liquidated damages I further agree to pay Aadvance Home Health Services reasonable cost incurred in compelling compliance with this agreement. Including but not limited to its legal fees.
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