Pre-Hire Forms

Employment Application

Personal Information

Full Name: *

Address: *

City: *

State: *

Zip: *

Phone Number: *

Mobile Number: *

Email Address: *

Are you legally authorized to work in the United States? *

Yes No

Preferred Method of Contact: *

Phone Email Text

Have you ever been convicted of, or pled guilty or nolo contendere to, a felony or any criminal offense that may affect your eligibility to work in a Florida home health agency or other healthcare setting? *

Yes No

IF YES, PLEASE EXPLAIN:

Position(s) You Are Applying For: *

Available Start Date: *

Employment Desired: *

Full Time Part-Time PRN / As Needed

Desired Hourly Pay: *

Education & Professional Credentials

School Name:

City/State:

Degree/Diploma/Certificate:

Major/Program:

Completed?

Yes No

School Name:

City/State:

Degree/Diploma/Certificate:

Major/Program:

Completed?

Yes No

Employment History

Employer Name (1):

Job Title:

From:

To:

Supervisor (if known):

Phone Number:

May We Contact:

Yes No

Primary Duties/ Responsibilities:

City/State:

Reason for Leaving:

Employer Name (2):

Job Title:

From:

To:

Supervisor (if known):

Phone Number:

May We Contact:

Yes No

Primary Duties/ Responsibilities:

City/State:

Reason for Leaving:

Employer Name (3):

Job Title:

From:

To:

Supervisor (if known):

Phone Number:

May We Contact:

Yes No

Primary Duties/ Responsibilities:

City/State:

Reason for Leaving:

Professional References

Name:

Relationship/Title:

Company:

Phone Number:

Email Address:

Name:

Relationship/Title:

Company:

Phone Number:

Email Address:

How did you hear about We’re No Different, LLC?

Internet Site: (i.e. Indeed/LinkedIn) Facebook Instagram Website Employee Referral Job Fair

APPLICANT ACKNOWLEDGMENTS Employment with We're No Different, LLC is contingent upon successfully meeting all applicable federal, state, AHCA, and agency pre-employment requirements. Depending on the position, these may include employment verification, professional license or certification verification, reference checks, Level II Background Screening, and other applicable requirements.

I authorize We're No Different, LLC to verify the information provided in this application, including my employment history, education, professional licenses or certifications, references, and any other information necessary to determine my qualifications for employment.

Applicants needing reasonable accommodation during the application or interview process should notify We're No Different, LLC so appropriate accommodations may be provided in accordance with applicable law.

Equal Employment Opportunity We're No Different, LLC is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to any characteristic protected by applicable federal, state, or local law.

APPLICANT CERTIFICATION I certify that the information provided in this Employment Application is true, complete, and accurate to the best of my knowledge. I understand that any false, misleading, incomplete, or omitted information may result in disqualification from employment consideration or, if hired, disciplinary action up to and including termination of employment.

By signing below, I acknowledge that I have read, understand, and agree to the statements contained in this Employment Application.

Applicant Name: *

Applicant Signature: *

Date *

Emergency Contact Information

Please complete this form in its entirety. This information will be used only in the event of an illness, injury, or emergency while you are working or representing We're No Different, LLC.

EMPLOYEE INFORMATION

Employee Name: *

Position: *

PRIMARY EMERGENCY CONTACT

Name: *

Relationship: *

Primary Phone Number: *

Secondary Phone Number (Optional):

Address (Optional):

SECONDARY EMERGENCY CONTACT (Optional)

Name:

Relationship:

Primary Phone Number:

Secondary Phone Number (Optional):

Address (Optional):

AUTHORIZATION

I authorize We're No Different, LLC to contact the individual(s) listed above in the event of an illness, injury, medical emergency, or other situation requiring notification while I am working or representing the agency. I understand it is my responsibility to notify We're No Different, LLC of any changes to this information.

Employee Signature: *

Date: *

Personal Information

Education & Professional Credentials

Employment History

Professional References

EMPLOYEE INFORMATION

PRIMARY EMERGENCY CONTACT

SECONDARY EMERGENCY CONTACT (Optional)

AUTHORIZATION

UPLOADS

TB RESULTS UPLOAD

PROOF OF COVID VACCINE UPLOADS