Employment at Omega Healthcare Services Omega healthcare services is always looking for good caregivers. We are growing and constantly taking on new clients. We have both Full-time, Part-time or Weekend hours. You tell us what hours you want to work, and we match you up with a client. We do however require at least one year experience, and the criminal screening service that we use is the best in the business. We also require your current CPR AND TB TEST RESULT. So if you are interested we would love to hear from you. Please email us your resume @ omegahealthcare@hotmail.com or fill the application form and someone will contact you if you are a good fit for any available position. PERSONAL INFORMATION Full Name: ______________________________________ Phone Number: _______________________ Address: ________________________________ Alternative Phone Number: _____________________ City: _____________________________ State: ______________________ Zip Code: _______________ Email Address: _____________________________________ Date of Birth: _______________________ Salary Requirement: __________________________ Are you 18 years and above Yes No If you are under 18 years old and we require a work permit, can you furnish one? If no, explain. ______ _____________________________________________________________________________________ __________________________________________ Available Start Date: _________________________ Have you worked for this company? Type of Employment Desired : Yes Full Time Are you a citizen of the United States? Yes No If yes, when? _____________________________ Part Time Temporary Seasonal Contract No If no, are you legally allowed to work in the United States? Yes No Have you ever pleaded “Guilty”, “No Contest”, or have been convicted of a crime? Yes No If yes, please explain with dates: __________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Driver’s License Number: ____________________________ Issuing State: ________________________ EMPLOYMENT HISTORY Name of Employer: ___________________________________ Date of Employment: ______________ Position Held: _________________________________ Address: ________________________________ __________________________________________________ Phone Number: _____________________ Supervisor’s Name/Title: ________________________________________________________________ Responsibilities: _______________________________________________________________________ _____________________________________________________________________________________ Starting Salary/Title: ___________________________ Ending Salary/Title:________________________ Reason for Leaving: _____________________________________________________________________ May we contact employer for a reference? Yes No Name of Employer: ____________________________________ Date of Employment: ______________ Position Held: _________________________________ Address: ________________________________ __________________________________________________ Phone Number: _____________________ Supervisor’s Name/Title: ________________________________________________________________ Responsibilities: _______________________________________________________________________ _____________________________________________________________________________________ Starting Salary/Title: ___________________________ Ending Salary/Title:________________________ Reason for Leaving: _____________________________________________________________________ May we contact employer for a reference? Yes No Name of Employer: ____________________________________ Date of Employment: ______________ Position Held: _________________________________ Address: ________________________________ __________________________________________________ Phone Number: _____________________ Supervisor’s Name/Title: ________________________________________________________________ Responsibilities: _______________________________________________________________________ _____________________________________________________________________________________ Starting Salary/Title: ___________________________ Ending Salary/Title:________________________ Reason for Leaving: _____________________________________________________________________ May we contact employer for a reference? Yes No I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial and other related matters as may be necessary for an employment decision. I hereby release employers, schools or individuals from all liabilities when responding to inquiries in connection with my application. In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge. Signature of Applicant _____________________________________________________________________________________ Date: ________________________________________________________________________________ List 3 References that are not related to you by blood. Reference # 1 Full Name: ________________________________________________________________ Phone Number: ________________________________ Address: _______________________________ ____________________________________________ Occupation: ______________________________ Reference # 2 Full Name: ________________________________________________________________ Phone Number: ________________________________ Address: _______________________________ ____________________________________________ Occupation: ______________________________ Reference # 3 Full Name: ________________________________________________________________ Phone Number: ________________________________ Address: _______________________________ ____________________________________________ Occupation: ______________________________