Alliance Care :: Apply Form

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Alliance Care is an Equal Opportunity Employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, gender, marital status, national origin, disability or handicap, or veteran status.

Please read carefully before you sign this application. It must be completed in full, even if you attach a copy of your resume.

Fields marked with (*) are required!

*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:

Home Phone:
Cellular Phone:
*Email Address:
Pay Rate Expected:
Preferred work location:

*Position applied for:

*On what date would you be available for work?:

(mm/dd/yyyy)

Only US citizens or aliens who have a legal right to work in the US are eligible for Employment. Can you, upon employment provide genuine documentation establishing your identity and eligibility to be legally employed in the United States? Yes No

Have you pled nolo contendere, been found guilty, or had adjudication withheld by the court, judge or jury for a crime that is a felony or first degree misdemeanor? Yes No

Answering "yes" does not constitute an automatic bar to employment. Factors such as date of offense, seriousness and nature of the violation(s), rehabilitation and position applied for will be taken into account.

If yes, please explain:

Have you ever been employed by Alliance Care, MMI or any of its affiliates? Yes No.

If yes please complete:

Location:		Position:
Manager's Name:		Dates Employed:

How were you referred to Alliance Care?

	Newspaper Advertisement		Current Employee		Employment Agency
	Internet Advertisement		Mailer		Other

Please give the specific name of the referral source:

PREVIOUS EMPLOYMENT HISTORY
Please complete the information regarding employment history beginning with the most current or previous employer.

Employer:

Street Address:

Job Title:

Dates Employed:

From:

To:

Salary:

Starting:

Ending:

Reason for leaving:

Manager:
Phone:
City:
State:
Zip:

Employer:

Street Address:

Job Title:

Dates Employed:

From:

To:

Salary:

Starting:

Ending:

Reason for leaving:

Manager:
Phone:
City:
State:
Zip:

Employer:

Street Address:

Job Title:

Dates Employed:

From:

To:

Salary:

Starting:

Ending:

Reason for leaving:

Manager:
Phone:
City:
State:
Zip:

Do you have any limitations, physical or otherwise, that preclude you from performing the functions of any job for which you applying?

Yes No If yes, is there anything that can be done to accommodate your limitation?

OTHER EXPERIENCE

Please check the areas in which you have had experience or special training:

	Home Health	Outpatient Rehab	Microsoft Power Point	Management Experience
	Medicare - Part A	Microsoft Word	Microsoft Outlook	Sales Experience
	Medicare - Part B	Microsoft Excel
Please list any other applicable skills you have acquired:

LICENSES / CERTIFICATIONS

Please list all health care licenses or certifications and provide a copy of each with your application.

Type of License / Certification:	License / Certification #:	Expiration Date:

EDUCATION

NAMES & LOCATIONS	DEGREE/ CERTIFICATION	FIELD OF STUDY	G.P.A.
High School:

College/University:

Dates Attended: From: To:
Graduate School:

Dates Attended: From: To:
Other School:

Dates Attended: From: To:

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) WILL BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

I authorize investigation of all statements I have made on this application. I authorize past employers, all references and any other persons to answer all questions concerning my ability, character, reputation and previous employment record. I release all such persons from any liability or damages arising from the disclosure of such information.

I agree to submit to a pre-employment physical, if required, and understand that employment is contingent upon satisfactorily completing it and any other testing procedures. I acknowledge the right of Alliance Care to require employees to require employees to take medical examinations in connection with my physical ability to perform the job, any background screenings for misconduct or illegal acts, drug screening or motor vehicle license check.

If employed, I understand that Alliance Care is committed to providing quality care to our clients. I agree to share this commitment without reservation. I further understand that due to the nature of services provided, an exceptional record of attendance and dependability is required of all employees.

If employed, I agree to comply and to be bound to all policies and procedures of the Company and be subject to the 90-Day Introductory period. If employed, I understand that the employment relationship exists at the will of management and employee for no definite period of time and that either party may terminate the relationship for any reason except those specifically prohibited by law. I further understand that neither the policies, rules, regulations of employment, or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract.

I understand that my application will normally be kept for 30 days after which time I would need to re-apply.

Questions regarding this statement should be directed to any interviewer before signing. The application, when completed in its entirety, will be given every consideration, but its receipt does not imply that the applicant will be employed.

REQUEST FOR TRANSCRIPT OF ACADEMIC RECORDS: I hereby authorize the educational institutions listed on the Employment Application to release a copy of the official transcript of my academic record.

*Date: (mm/dd/yyyy)

Signature: