* = Required Information

Application For Employment
Applicant's Last Name *
First Name *
MI *
Birthdate *
Date of application *
Street Address *
Types of work desired *
SS #
City *
State *
Zip *
Home Number *
Cell Number *
An Equal Opportunity Employer
Legend Home Health is an equal opportunity employer, and we do not and will not discriminate on the basis of race, color, religion, national origin, sex, gender preference, age, disability, marital or military status, or status as a disabled veteran. Information provided on this application will not be used for any discriminatory purpose and will be kept confidential.
Provide all information requested.
Are you at least 18 yrs of age? YesNo
If you are not a legal U.S. Citizen, have you the legal right to remain permanently in the US? YesNo
Have you ever been convicted of any crime or felony?(exclude traffic violations) or release from confinement following a conviction for any criminal offense YesNo
If yes, please give date, place and nature of each such conviction
Have you ever been arrested or terminated from any job for theft? YesNo
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? YesNo
What make, year, and model car do you drive? Is your car in good working condition? DL # Exp. Date: State:
Educational History
School name Location (City, State) Major course Or subject Circle year last completed Graduated Degree
High school
9 10
11 12
YesNo
College (list all attended)
1 2
3 4
YesNo
College (list all attended)
1 2
3 4
YesNo
Other From
To
YesNo
Professional/Work References
Name Title/relationship Address Phone no. Occupation
Lists any memberships in professional organizations, honors or activities which would enhance your application excluding groups that would indicate age, color, religion, military status, gender preference, sex, marital status national origin or disability.
List any spoken languages other than English:
List other skills or talents applicable to the position including computer experience, typing speed etc.
Employment Record or Work History
Starting with present or most recent, list all previous employers. including self-employment and summer and part-time jobs. If more space is required, please continue on a separate sheet. You may attach a resume, but complete this application as well.
Last or present company
Type of business
Street address, City, State, Zip Code Phone number Supervisor's name
Date start and left   Salary Reason for leaving OK to contact supervisor
FT PT
PT
YesNo
Brief description of job duties, responsibilities and accomplishments:
Last or present company
Type of business
Street address, City, State, Zip Code Phone number Supervisor's name
Date start and left   Salary Reason for leaving OK to contact supervisor
FT PT
PT
YesNo
Brief description of job duties, responsibilities and accomplishments:
Last or present company
Type of business
Street address, City, State, Zip Code Phone number Supervisor's name
Date start and left   Salary Reason for leaving OK to contact supervisor
FT PT
PT
YesNo
Brief description of job duties, responsibilities and accomplishments:
May we contact your present employer? YesNo
May we contact your references? YesNo
List professional license TYPE and number
State
Post-offer, pre-placement and reasonable cause testing - I understand that Legend Home Health may conduct post-offer and pre-placement controlled substance testing for prospective new hires. Additionally, controlled substance testing is conducted for any Legend Home Health employee when there is a reasonable belief that the employee may be using prohibited drugs. This is based upon observable behavior indicative or probable use or upon the theft of prescription medications from a specific client. Also, any "on the job" employee injury may require immediate drug testing. Refusal to submit or if there is a time lapse greater than one hour between injury and drug testing, an automatic termination will result.
Signature (Complete Name)
Date
Your complete application form will be maintained in our active files for six (6) months from the date of application. You may submit a new application at any time.
Position Applying for:
Work Schedule desired:
F T P T
Per Visit Wage
salary required
Shift
Day Night
Evening W/E
Date available
Areas of town you are willing to work

Security Code *
  Security code