First Name *

Last Name *

Street Address *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Zip *

Phone *

(###) - ### - ####

Cell

(###) - ### - ####

Pager

(###) - ### - ####

Email Address *

We will never sell or disclose your email address to anyone.

High School Name

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Major

College/University

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

College Degree

Professional/Tech School

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Major

How did you hear about Accredited

List Newspaper name, Search Engine, Friends Name, etc.

Position Desired

Hours Preferred

I hereby certify that the information is this application is correct and compete to the best of my knowledge. I understand that falsification or omission of any material information on this application or in the interviewering process or in my resume, or failure to pass a physical examination, may be sufficient cause for immediate termination if I have already received an offer of employment. I understand that this application will no longer be active or receive further consideration once the position for which I am applying has been filled, or I am employed but do not actively work for the Company for a period of six months or more.

I agree to have any of the statements herein as well as my background investigated by the Company or its agents. This authorization shall become effective immediately and shall remain in effect for a period of twelve months after the date of signing this authorization. I understand that the background investigation may include, but is not limited to, reviewing my education, employment history, any public records, and personal references, whether through a search of my social security number, name, or other identifying information. In consideration for reviewing my application and other related information, I hereby waive and release the Company, its employees and agents, and all other entities and persons from any claims I might have, including xxx defamation and invasion of privacy, arising out of any verbal or written inquires and/or any verbal or written responses related to investigation of my background as well as the use or disclosure of such information. I understand that a photocopy of this authorization is to be considered as valid as the original.

I agree that if employed, I will abide by all policies and procedures established by the company. I understand that my employment is “at will”, that I may resign at any time, that the Company may terminate my employment at any time, with or without cause, and that no employee or other representative of the Company has the authority to make an agreement contrary to the foregoing unless it is in writing and signed by the Company President. This constitutes my entire agreement with the Company with regards to the matters set forth In this paragraph.

By pressing the 'Submit' button on this form, I certify that all the information entered is true and complete to the best of my knowledge, and I understand that any false or missing job-related information may disqualify me from this position.

I agree to maintain confidentiality of all patient information including, but not limited to, names and addresses of clients and referral sources, patient medical condition and course of treatment, rates, etc.; and I understand that my failure to do so may result in disciplinary action up to and including discharge.

I California law requires us to provide medical treatment in the event you are injured at work. Accredited will provide this care by using a Medical Provider Network (MPN). I am aware that I must immediately notify the Company should I require treatment. Additional information regarding the MPN is available on http://www.accreditednursing.com website.

I agree that if employed, I will abide by all policies and procedures established by the company. I understand that my employment is “at will”, that I may resign at any time, that the Company may terminate my employment at any time, with or without cause, and that no employee or other representative of the Company has the authority to make an agreement contrary to the foregoing unless it is in writing and signed by the Company President. This constitutes my entire agreement with the Company with regards to the matters set fourth In this paragraph.

In connection with my application for employment/promotion/tenancy/care provider, including any contract for services, with you; I understand that a consumer report that may contain public information may be requested from TrustPoint, Inc.

I authorize, without reservation, any party or agency by TrustPoint, inc or one of its agents to furnish above mentioned information.

I have a right to make a request to TrustPoint, Inc., upon proper identification, of the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me, which TrustPoint, Inc. has previously furnished within the two-year periods preceding my request.

Residents of California, Maryland, Minnesota, and Oklahoma only; you have the right to receive a copy of your consumer report.

Applicants must provide city and state information for residence covering a period of seven (07) years. Begin with your most current address. If you are not sure of the address, include the city and zip.

The following is a list of the skills required for effective home health care. It is important that you can feel competent in these areas and can demonstrate expertise. Any skills that you have never done or you feel you cannot perform accurately, should you be identified. The procedure will be reviewed and learning experiences provided in those areas. You will be checked off under "demonstrated performance" by a skilled home health care nurse following understanding of the procedure/skill.

Please check corresponding number pertaining to your work experience/competency level using the following scale:

1 = Experienced, can perform without supervision
2 = Capable, can perform/operate
3 = Inexperienced with procedure/equipment; need supervision

* By submitting this application, I understand that I this online employment form may be used as an official document.