Avalon angels



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AVALON ANGELS

NURSING & CAREGIVER SERVICES INC.



1557 E. Amar Road, Ste. H, West Covina, CA 91792

Tel. # (626) 435-7755 * (909) 232-2777 Fax # (626) 388-9170



Thank you for your interest in working for Avalon Angels Nursing &Caregiver Services Inc. In completing this form, you have agreed not to hold the agency or the clients responsible for any accidents that may happen in the workplace. You are responsible for your taxes/social security as an independent contractor.

APPLICATION FORM

Applicant Information Date


Last Name




First

M.I.

Date of Birth

Street Address




Apartment/Unit #

City

State

Zip

Phone

( )

E-mail Address

Social Security No.

  • -

Male

Female

Height

Weight

Position Applied for:

Are you a citizen of the United States?

YES

NO

If no, are you authorized to work in the U.S.?

YES

NO

Have you ever worked for this company?

YES

NO

If so, when?




Have you ever been convicted of a felony?

YES

NO

If yes, explain







Availability:

Days

Nights

Weekend

Live-In Specify Available Hours :

Means of Transportation

I have a Car

Someone can drive me

Bus

DO YOU HAVE A CURRENT CALIFORNIA DRIVER’S LICENSE?

YES

NO

CDL#/CI.D #




DO YOU HAVE AUTOMOBILE INSURANCE COVERAGE?

YES

NO

Insurance No.




DO YOU HAVE MAL-PRACTICE INSURANCE?

YES

NO

If none please ask for application form from us

ARE YOU BONDED?

YES

NO

If not, please ask application form from us

DO YOU HAVE A CALIFORNIA STATE CERTIFICATION OR LICENSE? RN / LVN / CHHA / CNA

License #



Education


High School




Address




From




To




Did you graduate?

YES

NO

Degree




College




Address




From




To




Did you graduate?

YES

NO

Degree




Other




Address




From




To




Did you graduate?

YES

NO

Degree






PREVIOUS EMPLOYMENT


Company/Individual




Telephone No.




Address




Date Employed




Company/Individual




Telephone No.




Address




Date Employed




Company/Individual




Telephone No.




Address




Date Employed



References


Please list three professional references.

Full Name




Relationship




Company




Phone

( )

Address




Full Name




Relationship




Company




Phone

( )

Address




Full Name




Relationship




Company




Phone

( )

Address




WORK RELATED:





Do you have any experience in any of the following?

Alzheimer’s

Hoyer Lift

Heart Failure

Parkinson’s

Tracheal Tube

Lifting

Stroke

Gastric Tubes

Wheelchairs

Hip Surgery/Injury Patient

Diabetes

Colostomy

Back Surgery

Catheter Bag

Activities of Daily Living

Hospice Care

Range of Motion

Bed Bath

Cancer

Body Mechanics

Shower

Quadriplegia

Oral Hygiene

Bed making

Others:


Disclaimer and Signature


I certify that my answers are true and complete to the best of my knowledge.

If this application leads to engagement of my services, I understand that false or misleading information in my application or interview may result in my release.

I understand that any misrepresentation or omission of fact may result in legal action and/or justification for separation from Avalon Angels Nursing & Caregiver Services Inc.

I understand that all information on this form is subject to verification and I consent to criminal history background checks.



Applicant’s Signature




Date






EMPLOYMENT AGREEMENT


I understand that in signing a contract with Avalon Angels Nursing & Caregiver Services Inc. (the Agency), I will accept all responsibilities as a self-employed person, doing independent contract labor referred by Agency, I will not at anytime hold the Agency, Hospital, Patient, Family of the patient or agent of the patient, responsible in any way for my actions. I am completely responsible for my own State and Federal Income Tax, and Social Security withholdings.

I agree that I will not solicit or accept private employment from any client of the Agency. Should I solicit or accept an offer of employment from the agency’s client; I agree to indemnify the agency the amount of Three Thousand Dollars ($3,000) as placement fee.

I further agree that all disputes or cases arising from civil or criminal liability shall be filed in the Los Angeles county area.

I have read the foregoing and understand that I am giving permission to the Agency to write or speak to my former employers for employment references purposes.



Applicant’s Signature




Date




Form AF

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