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Help at Home, LLC/Oxford Healthcare Online Employee Application

Position Applying For:
How did you hear about this job? (Select a Source):
Help At Home Website
Job Board Advertisement
Walk-In
Employee Referral
We would like to thank the person who referred you.
Please provide the name:
Other (Please specify)
Please enter the location of the Help at Home/Oxford Office nearest to you? For a list of all Help at Home/Oxford locations click here.
Why are you interested in working at Help At Home, LLC?
PERSONAL INFORMATION
  Last Name First Name Middle Initial
 
  Address 1 Address 2
 
  City State Zip Code
 
  Home Phone Number Mobile Number
  () - () -
 
Email Address
Required fields are in RED
EMERGENCY CONTACTS
In case of emergency contact:
  Emergency Contact Name Relationship
 
  Phone Number
 
WORK EXPERIENCE
List the work, military or volunteering experience below. Specify the 3 (three) most recent entries.
1. Employer's Name:
  Street Address:
  City: State:
Zip Code:
  Phone: () - -
  Job Title: Immediate Supervisor and Title:
  Reason for leaving:
Dates Employed: FROM:
TO:
 
Below Summarize the nature of the work performed and job responsibilities:
Hourly Rate: START: FINISH:  
Salary: START: FINISH:  
May we contact for reference? NO LATER

2. Employer's Name:
  Street Address:
  City: State:
Zip Code:
  Phone: () - -
  Job Title: Immediate Supervisor and Title:
  Reason for leaving:
Dates Employed: FROM:
TO:
 
Below Summarize the nature of the work performed and job responsibilities:
Hourly Rate: START: FINISH:  
Salary: START: FINISH:  
May we contact for reference? NO LATER

3. Employer's Name:
  Street Address:
  City: State:
Zip Code:
  Phone: () - -
  Job Title: Immediate Supervisor and Title:
  Reason for leaving:
Dates Employed: FROM:
TO:
 
Below Summarize the nature of the work performed and job responsibilities:
Hourly Rate: START: FINISH:  
Salary: START: FINISH:  
May we contact for reference? NO LATER

Comments: (Feel free to include any additional information which can help us to make an employment decision. Please, explain any gaps in employment history as well)
EDUCATION
List the educational experience below. Start with the highest or the most relevant to the position.
High School Diploma/GED
Educational Institution 1 Program (Major) Degree
Educational Institution 2 Program (Major) Degree
LICENSURE AND CERTIFICATION
Start by entering the most relevant licensure or certification. Do not list expired ones.
License & Certificate Issuing Organization
Issue Date Expiration Date
Nursing License No.
Issuing Organization State
Issue Date Expiration Date
Experience Homecare Institutional Care
yrs.
Nurse Aide Certification No.
Issuing Organization State
Issue Date Expiration Date
Active Explain if not Active
PROFESSIONAL REFERENCES
Provide at least 3 (three) professional or school references. Please, do not include family members or other relatives.
Full Name
Phone Number
Professional Relation Years Known
1.
2.
3.
PRESCREEN QUESTIONNAIRE
1. Are you legally authorized to work in the United States?
YES
NO
2. Will you now or in the future require sponsorship for employment visa status (e.g., F-1, H-1B, TN status)?
YES
NO
3. Are you a preferred caregiver? (A person taking care of a family member/personal relative)
YES
NO
4. Do you have any family members/personal relatives currently working for Help At Home, LLC?
YES
NO
Please provide the name:
5. Have you ever worked at Help At Home, LLC or any of its affiliates, or subsidiaries?
YES
NO
If yes, please specify name (if different), position and dates:
AVAILABILITY
Indicate the employment preferences, conditions and interests.
Date of Availability Advance Notice (Weeks)
Days of the week you are available to work (check all that apply).
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
If you do not complete this application in its entirety we will not be able to process it. So recheck your work before clicking the "Submit Application" button.
By signing below.

TENNESSEE APPLICANTS ONLY
ABUSE & NEGLECT ACKNOWLEDGMENT AND RELEASE

Last Name First Name Middle Initial
Position Applied For:

Check this box and type in your name if you fully understand and agree to the terms above.
IMPORTANT: You must agree to the terms above and type in your full name in order for us to process your application.

*Qualified applicants receive equal consideration. No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, handicap, veteran status, marital status, sexual orientation, or any other characteristic protected by law.

*Help at Home, Inc/Oxford Healthcare is an equal opportunity employer.