Online Application

Please fill out the information for High School, College, Bus. Or Trade School, and Professional School if applicable:

Name of School	Location (City, State)	Number of Years Completed	Major & Degree

Have you ever been convicted of a crime?*
- Yes
- No
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentences(s) imposed, and types(s) of rehabilitation (A conviction will not necessarily result in the denial of employment):
Have you ever worked under a different name?*
- Yes
- No
If yes, what was it and what was the reason?

EMPLOYEE EMERGENCY NOTIFICATION
In case of Emergency, Please Contact:*
Name: Relationship: Address: Phone Number:
Second Emergency Contact:*
Name: Relationship: Address: Phone Number:
NOTIFICATION OF PROBATION PERIOD
I*
ACCEPT AND UNDERSTAND THAT THE FIRST 90 DAYS OF EMPLOYMENT WILL BE CONSIDERED MY PROBATIONARY PERIOD. IF FOR ANY REASON MY EMPLOYMENT IS TERMINATED DURING THIS PERIOD, I UNDERSTAND AND ACCEPT THAT THIS ACCOUNT WILL NOT BE CHARGED WITH ANY UNEMPLOYMENT BENEFITS THAT I MAYBE ELIGIBLE TO RECEIVE UNDER THE STATE OF FLORIDA UNEMPLOYMENT COMPENSATION LAW. I ALSO UNDERSTAND AND ACCEPT THAT AT THE END OF THE 90 DAY PERIOD, I WILL RECEIVE A WRITTEN EVALUATION OF MY WORK PERFORMANCE. SHOULD THE AGENCY FAIL TO PROVIDE THIS WRITTEN EVALUATION, IT SHALL BE UNDERSTOOD AND ACCEPTED BY ALL INVOLVED THAT THE PROBATIONARY PERIOD WILL HAVE BEEN COMPLETED SATISFACTORILY.
Type Name for Signature of Applicant:*
Date

CERTIFICATIONS/SKILLS
Please check any certifications/licenses you currently poses:*
- HHA
- CNA
- LPN
- RN
- Social Worker
- OH
- COTA
- Speech
- Marketing
Other
Skill Information:
I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE, AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Amerihealth Home Care permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release Amerihealth Home Care from any liability as a result of such contract.
Type name for Signature of Applicant:*
Date*
Amerihealth Home Care is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with Amerihealth Home Care depends solely on your qualifications.

Employment History
Employee Name: Name of Employer: Address: Telephone Number: Position: Dates of Employment: Supervisor Name: Reason for Leaving:

Click on the plus symbol to add employment.
If you have a Resume instead, please upload here.
Accepted file types: pdf, doc, docx.
Type name for Signature of Applicant:*
Date*