Welcome to Caregivers Home Health, Inc.
Thank you for applying for employment with Caregivers Home Health, Inc. Please take your time and fill out the application as completely as possible. We will need correct TELEPHONE and FAX numbers, and addresses when possible in order to check your three references.
Once we have received your completed application, and verified your references, we will make every effort to contact you as soon as appropriate when work is available. We will tell you if you have been hired, and set up a time for Orientation.
Age Requirement: 18 years +
For orientation we will need:
____1. Washington State Drivers License or Picture ID
____2. Social Security Card (must match your W-4 and picture ID)
____3. Auto Insurance (current)
If you have any of the following please bring with you at orientation.
If you do not, we will be able to assist you in obtaining them.
____4. CPR Card (current)
____5. CNA/RNA License
____6. HIV/AIDS Education Certificate
____7. Proof of TB Test/Chest X-ray
____8. Fundamentals/Modified Fundamentals of Caregiving Certificate
____9. Continuing Education Credits
____10. Nurse Delegation Certificate
____11. Verify residency: NEED (2) Copy of utility, phone, trash, cable or water bill with your name; property tax, lease agreement, or vehicle registration to verify residency.
If you’ve been searching for a Home Care Agency to work for that you can trust, you’ve come to the right place.
Locally owned by Rhonda Carrell RN, and a nurse in the community for over 30 years.
Again, thank you for applying with Caregivers Home Health, Inc.
Rhonda Carrell, R.N.
Rhonda Carrell RN
Nursing Administrator
Port Angeles Sequim Port Townsend Tacoma
3228 Hwy 101 East 136 S. 2nd Ave 2132 Lawrence St. (253) 474-9198
(360) 457-1644 (360) 683-7377 (360) 379-6659
Employee Application/Orientation/Pub/ Rev8-06 Page 0

CAREGIVERS HOME TEAM JOB APPLICATION
Port Angeles Sequim Pt. Townsend Tacoma
3228 Hwy. 101 E. 136 S. 2nd Ave. 2132 Lawrence St. 4301 S. Pine #517,
Port Angeles, WA 98362 Sequim, WA 98382 Port Townsend, WA 98368 Tacoma, WA 98409
(360) 457-1644 Fax: 457-8137 (360) 683-7377 Fax: 683-7880 (360) 379-6659 Fax: 379-5620 (253) 474-9198 Fax: 475-3190
1. Nursing License: ____NAR ___CNA ___RN ___LPN ___None Nursing License # _________________________
2. Date / Days/ Hours available for work: ____________________________________________________________
3. Do you have a legal right to work and remain in the United States? _____Yes _____No
(You may not work for Caregivers Home Health Inc unless you can present satisfactory proof of your identity and legal ability to work in the United States)
4. Will you accept assignments that require lifting, turning or moving of patients? _____Yes _____No
If “No”, you will not be denied employment for this reason.
5. If “Yes”, you can lift, turn or move patients, with and/or without accommodation, up to the following limits in pounds.
0 – 25 Yes____ No____ 25-50 Yes____ No____ 51-75 Yes____ No____ 76-100 Yes____ No____
Could be a problem? ___YES ___NO
6. How did you learn about Caregivers Home Health ?____________________________________________________
7. Have you ever been convicted of a felony? ________Yes ______ No
If yes, please give details ___________________________________________________________________________
________________________________________________________________________________________________
8. Have you ever been found guilty by a court of law of abusing, neglecting, mistreating, or misappropriating the property of an individual in a health care setting? ________Yes ________ No
If yes, please give details ___________________________________________________________________________
9. Do you have: A dependable car ______Yes ______ No
Driver’s license ______ Yes ______ No Automobile Insurance ______ Yes ______ No
Federal and State laws prohibit discrimination in employment because of race, color, sex, national origin, religion, age, equal pay and disability. We are
an equal opportunity employer. This application should not be construed as a contract of employment between the employer and the applicant or as a
promise of employment. I understand my employment is not guaranteed for any term, and my employment may be terminated by the employer or
myself at any time and for any reason with or without notice.
Employee Application/Pub/ Rev.1-05 /Orient To Sign /Page7A

Name ________________________________________ Phone __________________ Cell __________________
Address ______________________________________ Message Phone ________________________________
_____________________________________________ Emergency Contact ____________________________
Mailing Address ____________________________________________________ Social Security Card-Provide valid card at date of hire

JOB APPLICATION
Educational Background
Please explain any additional qualifications, education or training, including medication courses.
___________________________________________________________________________________________________________________
Prior Work History (List in order, last or present employer)
Company_________________________________________Supervisor______________________________________
Address__________________________________________ Phone__________________FAX___________________
_________________________________________________Salary________________________________________
Job Duties__________________________________________ Dates Worked From__________ To________________
Job Title____________________Reason for leaving______________________________________________________
Company_________________________________________Supervisor______________________________________
Address__________________________________________ Phone__________________FAX___________________
_________________________________________________Salary________________________________________
Job Duties__________________________________________ Dates Worked From__________ To________________
Job Title____________________Reason for leaving______________________________________________________
Company_________________________________________Supervisor______________________________________
Address__________________________________________ Phone__________________FAX___________________
_________________________________________________Salary________________________________________
Job Duties__________________________________________ Dates Worked From__________ To________________
Job Title____________________Reason for leaving______________________________________________________
I certify that the answers given in this application and in the employment interview (s) are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application and further authorize my former employers, government agencies, schools, and personal references to provide any information they have regarding me. I hereby release all employers, government agencies, schools, and personal references from any liability for providing information concerning me. If the results of this investigation do not meet the standards for employment required by law, licensure, regulations, or policies of the company, state, or federal authorities, I understand that an offer of employment may not be extended, may be revoked, or that my employment may be terminated.
In the event of employment, I understand that false or misleading information given in my application or interview (s) may result in discharge. I understand also that the Immigration Reform Control Act of 1986 requires that employers hire only U.S. citizens and aliens authorized to work in the United States and that all persons hired will be required to submit documents for verification to establish identity and employment authorization. In consideration of my employment, I agree to conform to the rules of either my employer or myself. I understand that no company representative other than the president has any authority to enter into any agreement for employment of any specified period of time, or to make any agreement contrary to the foregoing.
I understand that the employer reserves the right to provide other future employers with reference information concerning my performance during employment and the reason for ending my employment. I hereby consent to the release of such information. If employed, I agree to inform the company if I obtain any other employment while working for the company. I hereby acknowledge that I have read and understand the above statements.
Employee Application/Pub/ Rev.1-05/ Orient To Sign Page 7B

Attended Name City Graduated (circle) Certificate (circle)
High School Yes No Yes No
College Yes No Yes No
Other Yes No Yes No

EVALUATION
EXCELLENT
GOOD
FAIR
POOR
Job Knowledge
Quality
Quantity
Attitude
Dependability
Punctuality

Reference Letter/ Emp Orient To Sign Packet/Pub/Rev 8-06 Page 8

Reference Letter/Telephone Check

Former Employer_______________________________________________ Phone________________________________________
Address_______________________________________________________ FAX_________________________________________
_____________________________________________________________

I release the above named employer, Caregivers Home Health, Inc. and their agents and employees, from any liability or claims I may have which arise from any reference provided pursuant to this authorization or any authorized disclosure thereof.
X______________________________________________X X_______________________________________X
Applicant's Signature Applicant's Name (PRINT)
X________________________________X X_________________________X x______________________X Other (former) Name Social Security Number Dates Employed

Reason for leaving/Comments _____________________________________________________________________
Eligible for re-employment [ ] Yes [ ] No If no, please explain ______________________________________
Wage/Contract Rate: ___________ per hour Comments _______________________________________________
Name of Company: ___________________________________ Title: ____________________________________
X_____________________________________ X X__________________________________ X _____________X
Employer Signature Print name Date

____Port Angeles ____Sequim ____Port Townsend ____Tacoma
Dear ________________________________,
One of your former employees has applied for temporary assignment with Caregivers Home Health, Inc. We ask that you verify and complete this form at your earliest convenience and return it to our office. Thank you for taking the time needed to complete this reference form.
Very truly yours,
Rhonda Carrell
Human Resources
Caregivers Home Health, Inc.
P.O. Box 3157
Port Angeles, WA 98362

Employer to fill out below and sign

Application Page 3

EVALUATION
EXCELLENT
GOOD
FAIR
POOR
Job Knowledge
Quality
Quantity
Attitude
Dependability
Punctuality

Application Page 4

Employer to fill out below and sign

Reference Letter/ Emp Orient To Sign Packet/Pub/Rev 8-06 Page 9

Reference Letter/Telephone Check

Former Employer_______________________________________________ Phone________________________________________
Address_______________________________________________________ FAX_________________________________________
_____________________________________________________________

I release the above named employer, Caregivers Home Health, Inc. and their agents and employees, from any liability or claims I may have which arise from any reference provided pursuant to this authorization or any authorized disclosure thereof.
X______________________________________________X X_______________________________________X
Applicant's Signature Applicant's Name (PRINT)
X________________________________X X_________________________X x______________________X Other (former) Name Social Security Number Dates Employed

Reason for leaving/Comments _____________________________________________________________________
Eligible for re-employment [ ] Yes [ ] No If no, please explain ______________________________________
Wage/Contract Rate: ___________ per hour Comments _______________________________________________
Name of Company: ___________________________________ Title: ____________________________________
X_____________________________________ X X__________________________________ X _____________X
Employer Signature Print name Date

____Port Angeles ____Sequim ____Port Townsend ____Tacoma
Dear ________________________________,
One of your former employees has applied for temporary assignment with Caregivers Home Health, Inc. We ask that you verify and complete this form at your earliest convenience and return it to our office. Thank you for taking the time needed to complete this reference form.
Very truly yours,
Rhonda Carrell
Human Resources
Caregivers Home Health, Inc.
P.O. Box 3157
Port Angeles, WA 98362

EVALUATION
EXCELLENT
GOOD
FAIR
POOR
Job Knowledge
Quality
Quantity
Attitude
Dependability
Punctuality

Application Page 5

Employer to fill out below and sign

Reference Letter/ Emp Orient To Sign Packet/Pub/Rev 8-06 Page 10

Reference Letter/Telephone Check

Former Employer_______________________________________________ Phone________________________________________
Address_______________________________________________________ FAX_________________________________________
_____________________________________________________________

I release the above named employer, Caregivers Home Health, Inc. and their agents and employees, from any liability or claims I may have which arise from any reference provided pursuant to this authorization or any authorized disclosure thereof.
X______________________________________________X X_______________________________________X
Applicant's Signature Applicant's Name (PRINT)
X________________________________X X_________________________X x______________________X Other (former) Name Social Security Number Dates Employed

Reason for leaving/Comments _____________________________________________________________________
Eligible for re-employment [ ] Yes [ ] No If no, please explain ______________________________________
Wage/Contract Rate: ___________ per hour Comments _______________________________________________
Name of Company: ___________________________________ Title: ____________________________________
X_____________________________________ X X__________________________________ X _____________X
Employer Signature Print name Date

____Port Angeles ____Sequim ____Port Townsend ____Tacoma
Dear ________________________________,
One of your former employees has applied for temporary assignment with Caregivers Home Health, Inc. We ask that you verify and complete this form at your earliest convenience and return it to our office. Thank you for taking the time needed to complete this reference form.
Very truly yours,
Rhonda Carrell
Human Resources
Caregivers Home Health, Inc.
P.O. Box 3157
Port Angeles, WA 98362

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Human Resources (360) 457-1644

WSP/ Emp Orient To Sign Packet/Pub/Rev 8-06 Page 17

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Application Page 7

Application Page 8

Caregivers Home Health, Inc.

360-457-1644

91-1744106

3228 Highway 101 East Mailing Address: P.O. Box 3157

Port Angeles, Washington 98362

Accounting Department

(360) 457-1644

Signature:

Print Name:

Complete ALL shaded areas
C & D Only

Application Page 2

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Application Page 1

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WSP

Name__________________________________________Date Contacted_____________
Address_________________________________________________________________
Relationship_________________________How long known_______________________
Comments_______________________________________________________________
________________________________________________________________________

Personal References:

Name__________________________________________Date Contacted_____________
Address_________________________________________________________________
Relationship_________________________How long known_______________________
Comments_______________________________________________________________
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Personal References:

Name__________________________________________Date Contacted_____________
Address_________________________________________________________________
Relationship_________________________How long known_______________________
Comments_______________________________________________________________
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Personal References:

X_______________________________________________________________________X
Employee Signature Date