Job Application 3 Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATIONName *FirstMiddleLastPosition Applied ForDate of ApplicationHome PhoneCell PhoneEmail *Present Street AddressSocial Security Number *Are you able to perform the essential functions of the position for which you are applying, either with or without reasonable accommodations?YesNoDo you have the legal right to work and be employed in the U.S.? (Proof of identity and legal authority to work in the U.S. is a condition of employment)YesNoAre you at least age 18? (Proof of age and work permits may be required prior to hiring)YesNoDo you have a reliable means of transportation to and from work?YesNoUpload Resume Click or drag a file to this area to upload. EDUCATIONJunior High EducationEnter Name of School and Address; Graduated (Yes/No); Number of Years; Course or Major; Grade Point AverageHigh SchoolEnter Name of School and Address; Graduated (Yes/No); Number of Years; Course or Major; Grade Point AverageCollegeEnter Name of School and Address; Graduated (Yes/No); Number of Years; Course or Major; Grade Point AverageOther EducationEnter Name of School and Address; Graduated (Yes/No); Number of Years; Course or Major; Grade Point AverageExtracurricular Activities (You may omit those which indicate your race, color, religion, sec, national origin, ancestry, age, the existence of a disability or any other characteristic protected by law.)Have you ever worked for Alexus Home HealthCare, Inc. before?YesNoEqual Opportunity InfoAlexus Home HealthCare, Inc. is an equal opportunity employer. Alexus Home HealthCare, Inc. does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable state or federal civil rights laws.GENERAL INFORMATIONDate available to startWork StatusFull-TimePart-TimeAvailabilityEnter Available Work Time for Each Day including weekends (Ex. Mon: 9am - 5pm; Tuesday: 9am - 5pm, etc.)What interested you in Alexus Home HealthCare, Inc.? What are your hobbies, special interests, and activities? (Please omit those indicating race, color, religion, sex, national origin, ancestry, age, the existence of a disability or any other characteristic protected by law.) Have you ever been convicted of a crime other than a traffic violation?* (NOTE: Please exclude misdemeanor convictions for marijuana-related offenses more than two years old; convictions that have been sealed, expunged, or legally eradicated; and misdemeanor convictions for which probation was successfully completed or otherwise discharged and the case was judicially dismissed. A conviction is not an automatic bar to employment. Each case will be considered on its own merits.) YesNoIf Yes, please explain and state the charge, the court, the date of the conviction, and the disposition of the case:Felony Info Laws Part 1NOTE: Some states limit the types of crimes (e.g., felonies) for which information can be sought and the time frame for which employers can inquire about convictions. Some state and local government laws afford independent protections to individuals with convictions by requiring employers to postpone questions about convictions beyond the application stage, by prohibiting such questions altogether, or by establishing protocols and restrictions regarding the use of conviction information. Employers should consult with their legal counsel if they wish to pose any question about convictions, including the question on this form, to determine if it is allowed in all applicable jurisdictions.Felony Info Laws Part 2** Some laws prohibit employers from seeking salary history information about an applicant, e.g., Labor Code Section 432.3. Employers that are subject to such laws should not inquire about rate of pay.EMPLOYMENT/WORK EXPERIENCEWork Experience InfoPlease list all of your jobs in the past five years. (If applicable, you may list work performed on a voluntary basis. If additional pages are needed, please attach.)Company No. 1: (present or most recent employer)Company Name; Address; Telephone Number Company No. 1: Employed (Month and Year)From and To Dates (ex. January 2013 - March 2018)Company No. 1: Rate of PayStart and Ending Pay (ex. $15.00 - $25.00)Company No. 1: Average Number of Hours Worked Per WeekCompany No. 1: Position(s) HeldList of all positions held in company (ex. Medical Assistant, Nursing Assistant, Physician)Company No. 1: Supervisor's Name and Position Company No. 1: Describe all of your significant dutiesCompany No. 1: May we contact this employer?YesNoCompany No. 1: Reasons for leavingCompany No. 2: (next or most recent employer)Company Name; Address; Telephone Number Company No. 2: Employed (Month and Year)From and To Dates (ex. January 2013 - March 2018)Company No. 2: Rate of PayStart and Ending Pay (ex. $15.00 - $25.00)Company No. 2: Average Number of Hours Worked Per WeekCompany No. 2: Position(s) HeldList of all positions held in company (ex. Medical Assistant, Nursing Assistant, Physician)Company No. 2: Supervisor's Name and PositionCompany No. 2: Describe all of your significant dutiesCompany No. 2: May we contact this employer?YesNoCompany No. 2: Reasons for leavingCompany No. 3: (next or most recent employer)Company Name; Address; Telephone Number Company No. 3: Employed (Month and Year)From and To Dates (ex. January 2013 - March 2018)Company No. 3: Rate of PayStart and Ending Pay (ex. $15.00 - $25.00)Company No. 3: Average Number of Hours Worked Per WeekCompany No. 3: Position(s) HeldList of all positions held in company (ex. Medical Assistant, Nursing Assistant, Physician)Company No. 3: Supervisor's Name and PositionCompany No. 3: Describe all of your significant dutiesCompany No. 3: May we contact this employer?YesNoCompany No. 3: Reasons for leavingPlease identify and explain all periods of unemployment during the last five yearsFrom; To; Reason for Unemployment (ex. January 2014 - February 2014, Laid off)Certification Part 1I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by Alexus Home HealthCare, Inc. unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom Alexus Home HealthCare, Inc. contacts, to provide Alexus Home HealthCare, Inc. any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to Alexus Home HealthCare, Inc. as well as from any use or disclosure of such information by Alexus Home HealthCare, Inc. or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment.Certification Part 2In consideration of my employment, I agree to conform to the rules and standards of Alexus Home HealthCare, Inc.. I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of Alexus Home HealthCare, Inc.. I understand that no employee or representative of Alexus Home HealthCare, Inc., other than its president, has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implied agreement contrary to the foregoing. Further, the president of Alexus Home HealthCare, Inc. may not alter the at-will nature of the employment relationship or enter into any employment agreement for a specified time unless the president and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this shall constitute a final and fully binding integrated agreement with respect to the at-will nature of my employment relationship and that there are no oral, written, or collateral agreements regarding this issue.Certification Part 3I also understand that all offers of employment are conditioned on Alexus Home HealthCare, Inc.'s receipt of satisfactory responses to reference requests and the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States. Offers of employment are also conditioned on the satisfactory completion of a post-offer medical examination.Submit Alexus Home Healthcare, Inc. is a for profit corporation Medicare Certified Agency About Us Careers Help Center Contact Us Designated agency personnel are available on an on-call basis during non-office hours including weekends and holidays. For more information, please contact: Alexus Home HealthCare, Inc. 4000 Long Beach Blvd., Ste. 221 Long Beach, CA 90807 Phone: (562) 637-3113 Fax: (562) 637-3115 Office Hours: Monday to Friday 9:00 am to 5:30pm © 2023 Alexus Home Healthcare, Inc.
