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Employment Application

PERSONAL INFORMATION
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone
Are you 18 years or older*
DESIRED EMPLOYMENT
Poistion you are applying for:*
Desired Salary
Start Date*
Date Format: MM slash DD slash YYYY
Are you currently employed?*
May we inquire of your current employer?*
Have you ever worked for this company?*
Who referred you to Impact Life Healthcare?
- Friend
- Employee
- Advertisement
- Government Placement Agency
- Internet
- Other
Specify
CURRENT EMPLOYER
Current Employer
Telephone
Reason for leaving
Name of last supervisor
EMPLOYMENT HISTORY
Name of Employer 1
List your last two (2) employers, assignments of volunteer activities, including experience. Explain any gap in employment in the comments section below.
Job Title
Address*
Street Address Address Line 2 City State ZIP Code
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
What was the nature of your work?*
Hourly rate
Name of supervisor
Phone
Comments
Name of Employer 2
Job Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
What was the nature of your work?*
Hourly rate
Name of supervisor
Phone
Comments
ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?*
(Proof of eligibility will be required before employment)
EDUCATION
High School
Name of School & Location
Number of years attended
Did you graduate?
Major
College | University
Name of School & Location
Number of years attended
Did you graduate?
Major
Professional Training
Name of School & Location
Number of years attended
Did you graduate?
Professional Certification
EMERGENCY CONTACT
Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Relationship
PERSONAL REFERENCES
Professional Reference 1 - Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
Business
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Professional Reference 2 - Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
Business
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Have you been convicted of a crime in the last 5 years?*
Please explain (Will not necessarily prevent your employment)
Please check the box*
- I certify that the facts contained in this application are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for a subsequent discipline up to and including dismissal from employment if discovered at the later date. I understand that if employed, 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 prior notice. No representative of Impact Life Healthcare other than the owners is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owners.
CERTIFICATION
Check all that apply*
- Select All
- RN
- LPN
- GNA/CNA
- Other
State
Please list certification
SKILLS
The following information will help us place you where your skills, knowledge of nursing and preferences will be best suited
Can you do vital signs
Can you do nurses notes?
Can you do catheter care?
Can you insert catheters?
Can you start IVs?
Do you suction patients
Can you set up oxygen for patients?
Can you do neurological Assessments?
Can you give intramuscular medications?
Can you give IV medications?
Can you assess patients for admission?
Can you discharge patients?
Have you had CPR?
Do you have intensive care experience?
In which of the following areas have you had experience??
Have you had any special training in nursing? If so, what?
Preferences
Are you a licensed driver?
Will you travel 30 minutes one way?
Are you a licensed driver?
Will you work shifts at a hospital?
Will you work shifts at a nursing home?
Will you work private duty cases?
Please rate your physical condition.
Select the time of day you are available
Select your days of availability
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
How many hours a week do you wish to work?
Do you have any handicaps? If so, please describe:
If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Impact Life Healthcare. This application will remain on the active file for 60 days. If I am hired within this period, this form will be transferred to my individual personal file. If I am not hired or have not heard from this agency within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with Impact Life Healthcare.

I do hereby give the employer and/or its agents, including consumer-reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but is not limited to, credit reports, criminal conviction records, motor vehicle driving records, and previous employment history. Further, I hereby release from liability and hold harmless Impact Life Healthcare and, its representative, all persons and organizations/companies for furnishing such information.

If required, I agree to a drug-testing prior to and during employment or for post-accident occurrences. The employer, Impact Life Healthcare is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report, which includes information as to your character, general reputation, personal characteristics, and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.”
Signature*
Date
Date Format: MM slash DD slash YYYY
Please attach photocopies of the following.
- Birth Certificate
- Drivers License
- Copy of Social Security card
- Employment Authorization/Eligibility
- CPR Certifications (if any)
- Professional License (if any)
- First Aid Certificate(if any)
- BLS Unrestricted professional Lic (if any)
- Criminal background check using CJIS #
File
Drop files here or

Accepted file types: pdf, jpg.

About Impact Life Healthcare

Impact Life Healthcare embraces a holistic approach to health and wellness. Inherent in our mission is the belief that patient education promotes a healthier society. .

Learn more

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Business Information

Hours: Mon - Fri | 9:00am - 5.30pm

Phone: 301-792-1469 (MD)
Phone: 804-833-6052 (VA)

Address:
- 6801 Kenilworth Avenue Suite 300-S13 Riverdale MD 20737

-3203 Maury Street, Richmond VA 23224

Home Care License Numbers:

- HCO-232739(Virginia)
- R5151(Maryland)
- Group Home License Number: 4548-01-001

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Supercharge your career

Employment Application

Employment Application

PERSONAL INFORMATION

DESIRED EMPLOYMENT

CURRENT EMPLOYER

EMPLOYMENT HISTORY

EDUCATION

High School

College | University

Professional Training

EMERGENCY CONTACT

PERSONAL REFERENCES

CERTIFICATION

SKILLS

Preferences