:: Assisted Living in Florida ::

Name,Address and Telephone of Employer

# of beds

Type of Job

Employment Dates

Hours worked

Reason for Leaving

Salary

Text Size


EMPLOYEE INFORMATION:
Applying For:

HHA	CNA	Manager	Administrator

*Our organization does not employ LPNs and RNs.

First Name*

Middle Name

Last Name*

How did you find us?

Agency Name

Describe

Cell Phone*		- -

Alt Phone		- -

E-mail*

Address*

City*

State*

Zip Code*

Date Of Birth*

Place of Birth*:

Social Security Number*:		- -

Re-enter Social Security Number*:		- -

Sex* :		Male Female

Race*:

Eye Color*:

Hair Color*

Height*:

Weight*:		Lbs

Country of citizenship*

Your experience with computers
I have never used computers.
I can check my emails and use the Internet.
I use computer for everyday functioning.

JOB RELATED TRAINING AND CERTIFICATIONS
Requirement	Hours	Certification Date	Remarks
TB Test
Background check
CPR
AED
First Aid
Nutrition
Medication
Medication
Direct Care
Direct Care
Infection Control
Aids/Hiv
Alzheimer’s I
Alzheimer’s II
Elopement
DNR
HHA
CNA
Other

EMPLOYMENT:

Currently Working*:

Yes No

Previous Work Experience*:

Yes No

Preferred Position :

Day Shift Live-In Shift Both

Managerial Administrative

Salary Expected* :

Not less than per hour.

Do you currently drive ?

Yes No

How long have you worked in the ALF industry ?

Years

Months

Please tell us about your ALF experience :

REFERENCES*:

MEDICAL INFORMATION:

Diagnosis
Allergies :				Yes No
If Yes, Name Allergies:
Do you wear eyeglasses:				Yes No
Do you have Hearing aids :				Yes No
Do you have BP Issues?				Yes No
Are you on BP Medications ?				Yes No
Are you Diabetic?				Yes No
If Yes, Are you insulin dependent?				Yes No
Do you have tuberculosis or any other communicable disease?				Yes No
If Yes, describe
Are you physically fit to work in ALF?				Yes No

BACKGROUND INFORMATION

*Are you legally authorized to work in United States?		Yes No
Florida law requires certain employees of assisted living facilities to be background screened. This includes a search of the Department of Children & Families Abuse Registry, an FDLE Criminal Background Check, and may include an FBI fingerprint check.
Have you already had a background screening conducted?(Charges for Background screening will apply)		Yes No
If yes,how long ago?
How may we obtain a copy of that screening?
*If no, do you object to having that screening conducted?
*Have you ever had any abuse or neglect cases against you ?		Yes No

CONSENT:

Why should we hire you?*
I consent to an investigation of all statements contained in this application.I certify that to the best of my knowledge and belief,all of the statements contained herein and on any attachments are true, correct,complete, and made in good faith.I am aware that any omissions,falsifications, misstatements, or misrepresentations may disqualify me from employment,or may be grounds for termination at a later date.
Signature*			Date*

Type the characters you see


The form can be submitted electronically or by Fax: 954-255-3471 or by mail at : AssistedLivingInFlorida.com 1780 N.W. 112th Terrace Coral Springs,Florida 33071. Resume can be attached if available.

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