Health Care Services Pool
Home Care and Companion Services

  • PERSONAL INFORMATION Step 1
  • EDUCATION Step 2
  • REFERENCES Step 3
  • EMPLOYMENT HISTORY Step 4
  • Notice of Agreement Step 5

PERSONAL INFORMATION

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AVAILABILITY
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Morning Morning Morning Morning Morning Morning Morning
Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon Afternoon
Evening Evening Evening Evening Evening Evening Evening
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EDUCATION

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Name of School Address Number of Years Completed? Major/Degree
High School *
College *
Trade School
Graduate School

REFERENCES

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*    Yes   No

If yes, please explain the number of convictions, the nature of the offense(s) leading to the conviction(s), how recently was/were the offense(s) committed, sentence(s) imposed, and type(s) of rehabilitation.

PLEASE LIST TWO PERSONAL REFERENCES

Reference 1 *
Reference 2 *

EMPLOYMENT HISTORY

* Required fields

Please list your work experience starting with your most recent employer.

Employer Name Address and Phone Number * Employment dates

From: *

To: *

Name of Last Supervisor * Last Job title: *
Job Duties and Responsibilities: * Reason for Leaving: *

Please list any additional skills, qualifications, certifications, or training that you feel is relevant to this position (e.g., speak a foreign language, CPR, or other training or special education). *

Specialty: Check all that apply
Medical/Surgical Mental Health Wound Care
Neuro Hospice Other
Pediatrics Home Health Care
Orthopedics Long-term care
Health Care Experience
less than a year 1‐3 years 3‐5 years More than 5 years
* Yes No If so, in which states?
Please insert Driving License number.
* Yes No
If so, in which states?

Please insert each Nursing License number.

* Yes No
* Yes No
If yes so, explain

Notice of Agreement

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In exchange for this job application, DeRBee Nursing Education Mentoring and Partnership Network LLC, also known as DeRBee Nursing Network agrees 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 promises continuous employment.
  • Both the undersigned and DeRBee Nursing Network may end the employment relationship at any time.
  • I further understand that my employment with the DeRBee Network shall be probationary for a period of ninety (90) days, and further that at any time during the probationary or thereafter, my employment relationship with DeRBee Nursing Network is terminable at will for any reason by eitherparty.
  • 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 DeRBee Nursing Network permission to contact educational institutions, all previous employers (unless otherwise indicated), references, and perform a criminal background check conducted by ACHA as required by state law. I hereby release DeRBee Nursing Network from any liability as a result of such contact.
E- Signature of Applicant:
Sign



Date:

DeRBee Nursing Education Mentoring and Partnership Network LLC, is an equal employment opportunity company. Therefore, we do not discriminate against employees based on race, gender, religion, sexual orientation or nationality.