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Employment Application

Name
Date
Address
City
State
Zip Code
Phone
Email
Over 18 Years Old
Position Applying For
Date Available
Hours/Days Available
If applying as a Home Health Aide, are you State Tested?
Number of years experience in Home Care
Employment History:
Starting with most recent, please list previous employment.

Company Name
Position
Supervisor/Contact
Dates Employed
Reason Left


Company Name
Position
Supervisor/Contact
Dates Employed
Reason Left


Company Name
Position
Supervisor/Contact
Dates Employed
Personal References:
List 3 people not related to you, whom you have known for at least 1 year.

Name
Phone
Yrs Acquainted


Name
Phone
Yrs Acquainted


Name
Phone
Yrs Acquainted


Have you ever been convicted of a felony?
Do you have a valid driver's license?
Do you have current automobile insurance coverage?


*You must maintain a valid driver's license and automobile insurance coverage at all times to be eligible to work at Advantage.
Highest Education Completed
Other Training/Education
 

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Call 740-354-5671 today and ask Laura or Tracy how Advantage can help you.

Contact Us:
Advantage Skilled Care, L.L.C.
1656 Coles Blvd. Portsmouth, Ohio 45662
Phone: 740-354-5671 or 1-800-636-2330  |  Fax: 740-354-4432  |  E-mail: Advantage Skilled Care, L.L.C.

For PASSPORT and private pay services, visit our sister agency at:
Advantage Home Health Care, Inc.
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