Licensed by the Arkansas Department of Health and Human Services
870-425-2446
Request Information Frequently Asked Questions Employment Services Photos Resources Why Choose Us Home
Homebound Home Healthcare - Mountain Home, AR
Date: *
Name: *
Last
*
First
*
Middle

Address: *
Street Address
*
City
*
State
*
Zip

Phone: * Social Security #:
Cell Phone: Best Time to Call:
Email: *





Are you legally eligible for employment in the U.S.A.?

Yes       No
(if hired, you are required to submit proof of your eligibility to work in the U.S.A.)


Are you over the age of eighteen?
Yes       No
(If no, hire is subject to verification that you are of minimum legal age.


Position (s) applied for:    


Do you have any physical or other limitations that would keep you from performing your job?
Yes       No


Are you licensed or certified?
None       HHA       CNA       LPN       RN      


What date will you be available to work?    


Are there any other job related experiences, skills or qualifications which will be of special benefit in the job for which you are applying?

* Required Fields


     
CONSENT FORM


I,* , hereby give my consent to any and all previous employers of mine to provide information regarding my employment with previous employers to HOME BOUND MEDICAL of Mountain Home, Arkansas. This consent is given in accordance with Act 1474 of the 1999 General Assembly of the State of Arkansas.
  • Date and duration of employment
  • Current pay rate and wage history
  • Job description and duties
  • Last written performance evaluation prepared before the date of the request attendance information
  • Results of drug and alcohol test administered within one year before request
  • Threats of violence, harassing acts, and/or threatening behavior related to the workplace or directed at another employee
  • Whether the employee was voluntarily separated from employment and the reasons for the separation
  • Whether the employee is eligible for rehire



* Re-enter Applicant Name to verify consent

*Required Fields


     
ACKNOWLEDGEMENT


PLEASE READ BEFORE SIGNING

IF YOU HAVE ANY QUESTIONS REGARDING THIS STATEMENT, PLEASE CONTACT US

In the event of my employment by HOME BOUND MEDICAL, I will comply with all the rules and regulations set forth in the employee manual and other communications available to all employees.

In processing this employment application, I understand that HOME BOUND MEDICAL may request an investigative consumer report be prepared. This report may include information as to my character and general reputation. It may also include (1) a credit bureau report to ensure that I have good credit, and (2) an investigative from police and FBI to ensure that I have no criminal record. I have the right to request that HOME BOUND MEDICAL disclose to me the nature and scope of such investigation if I make the request within reasonable time after completing this application.

I understand that this application will remain active for 30 days and that, if employed, I will be on probationary status for the next 6 months of employment in accordance with the HOME BOUND MEDICAL personnel policy manual.

I hereby acknowledge that I have read the above statement, understand same, and certify that the information contained in this application is correct and complete to the best of my knowledge and belief. I understand that knowingly making a false statement or omission in this application may be sufficient cause for rejection of this application or for dismissal after employment.

*
Applicant Name

*
Birthdate for referenced reporting

*
Date

* Required Fields

     
EMPLOYMENT HISTORY
List below present and past employment, beginning with your most recent


Employer I
Name and Address of Company,
Type of Business and Phone
From (Mo./Yr.): To (Mo./Yr.):
Weekly Starting Salary Weekly Last Salary
Reason for Leaving
Name of Supervisor
Describe the work you did:

Employer II
Name and Address of Company,
Type of Business and Phone
From (Mo./Yr.): To (Mo./Yr.):
Weekly Starting Salary Weekly Last Salary
Reason for Leaving
Name of Supervisor
Describe the work you did:

Employer III
Name and Address of Company,
Type of Business and Phone
From (Mo./Yr.): To (Mo./Yr.):

Weekly Starting Salary Weekly Last Salary
Reason for Leaving
Name of Supervisor
Describe the work you did:

Employer IV
Name and Address of Company,
Type of Business and Phone
From (Mo./Yr.): To (Mo./Yr.):

Weekly Starting Salary Weekly Last Salary
Reason for Leaving
Name of Supervisor
Describe the work you did:


I hereby give permission to contact the employers listed above
concerning my prior work experience as indicated below.
Employer I? Yes No
Employer II? Yes No
Employer II? Yes No
Employer IV? Yes No


Applicant Name

Date

     
RECORD OF EDUCATION


School Name and Address
of School
Course of
Study
Last Year
Completed
Did you
Graduate?
List Diploma
or Degree
Elementary 5
6
7
8
Yes
No
High 1
2
3
4
Yes
No
College 1
2
3
4
Yes
No
Other
(Specify)
1
2
3
4
Yes
No


PERSONAL REFERENCES (Not Former Employers or Relatives)
Name and Occupation


Address


Phone Number




May we telephone you to follow up on this application at home? Yes   No
If yes, what is the best time to call?
May we telephone you to follow up on this application at work? Yes   No
If yes, what is the best time to call?
What is your business telephone number?



Applicant Name




Follow us on Facebook 358 Hwy. 5 North • Mountain Home, Arkansas 72653 • (870) 425-2446   © 2015 - 2018