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.:: Employment Application ::.

First name Marital Status Married    Single
Last name Date of Birth
Address Social Security #
City Phone Number
Province Email Address
Postal Code Classidifation
Licence number    
EDUCATION : list nursing scool and/or college
Name & Location of School Month & Year of Graduation D=Degree C=Certificate & Date Issued

WORK REFERENCES: List below starting with your current or latest employer. These references must relate to the position for which you are applying.
Name of facility Location Phone Number Dates Employed Reason for leaving or presently working
 CPR Certification Date    

Do you have any experience in any of the following areas?
Date's (Years) & where you had the experience .
Note: These experience's must correspond to your experience under*present Licensure. Please also include types of experience, and comfort level of experience.
Neo-Natal IV Pediatric
Home Care Ventilator Nursing Home
Med/Surg Cath/Foley Trach Care
Hospitals Hospice CCU
Rehabilitation ICU Well Baby
Feeding Tubes : Pediatric     Adult

Days       Evenings       Nights       Anytime      
Weekends       Weekdays      

  1      Date :        Shift :      AM         PM         ND
  2      Date :        Shift :      AM         PM         ND
  3      Date :        Shift :      AM         PM         ND
  4      Date :        Shift :      AM         PM         ND
  5      Date :        Shift :      AM         PM         ND
  6      Date :        Shift :      AM         PM         ND
  7      Date :        Shift :      AM         PM         ND
  8      Date :        Shift :      AM         PM         ND
  9      Date :        Shift :      AM         PM         ND
  10    Date :        Shift :      AM         PM         ND
  11    Date :        Shift :      AM         PM         ND
  12    Date :        Shift :      AM         PM         ND
  13    Date :        Shift :      AM         PM         ND
  14    Date :        Shift :      AM         PM         ND

We may contact the employers listed above unless you indicate
those you DO NOT want us to contact:

US CITIZEN Yes     No     IF not, resident card #

LANGUAGE ABILITY : Please indicate if you can speak any foreign languages .
English     French     Yes, i do speak a foreign language :

Name        Address        Phone
Do you work another job? Yes    No    Can we call you there Yes    No    if Yes, please complete :
Company Phone #
Days Floor
Hours Availabitity
Have you ever been convicted of a crime? Yes    No

I certify that I am not addicted to any depressants, stimulants, narcotics, drugs, alcohol, or other substances that may alter my behavior. Any falsification will be sufficient grounds for my release from employment. I have been informed by Kahak Health Care that random drug screens will be performed.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed; falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

Under no circumstances, without the prior written consent of Kahak Health Care, LLC may I to be employed directly or indirectly for any client or member of the family of any client for whom I have cared for as an employee of Kahak Health Care

By clicking Submit you are certifying that all of the above information is correct and complete:

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