* = Required Information
Employee Information

It is the policy of BB Angels Home Health Agency INC to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

Applicant Information
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Emergency Contact

Yes No
Yes No
Yes No
Yes No
Yes No

I was convicted on in ,

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT

Applicant's Skills

List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5

Skills Inventory: Check the area in which you have experience or training

Experience Training
Experience Training
Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application.



Applicant's Education and Training
Yes No
Yes No
Yes No
References

List any two non-relatives who would be willing to provide a reference for you.


BACKGROUND CHECK CONSENT FORM

As a prospective employee of the Agency I understand that it is the Agency's policy to secure conviction criminal history information as part of their pre-employment screening process.

I authorize the Agency to use the information for the sole purpose of obtaining a conviction only Criminal History File Search.

CERTIFICATION

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize BB Angels Home Health Agency INC to contact former employers and educational organizations regarding my employment and education.I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades.I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Security code