EMPLOYMENT APPLICATION Step 1 of 7 14% CROSSWAY COMPANIESEMPLOYMENT APPLICATIONYour Name Last First Middle Email PhoneDate MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Date Available: MM slash DD slash YYYY Desired salary ($):Social Security No:Position You're Applying ForNon-Clinical Nurse SupervisorClinical Scheduling and Medical RecordsIntake and ReferralsNon-clinical scheduling Have you ever been convicted of a felony? Yes No If yes, explain?Have you ever worked for this company? Yes No If yes, explain?Have you lived outside of Massachusetts for the past 7 years? Yes No If yes, Where? Please list all states.By Signing below, I provide my consent to a Cori check and affirm that the information provided above is true and accurate. Please be advised that we will run a Cori background check in all states you listed above.Signature of CORI subjectDate MM slash DD slash YYYY EducationHigh school:Address:From MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate?YesNoDiploma:College:Address:From MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate?YesNoDiploma:Other:Address:From MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate?YesNoDiploma:Licenses and CertificationsLicense or CertificationID NumberStatusExpiration DateStateLicense or CertificationID NumberStatusExpiration DateStateReferral InformationHow did you hear about us? (Please check) Newspaper Ad Internet Current Employee Other If refered please provide employee name. (We’d like to thank them)I hereby give permission for my previous employer to release this referral information about my position with their company and comments regarding my work ethic and character while in their employment.Applicant’s SignatureDate MM slash DD slash YYYY ReferencesPlease list three professional references.Full NameRelationshipCompanyPhoneAddressEmail Full NameRelationshipCompanyPhoneAddressEmail Full NameRelationshipCompanyPhoneAddressEmail Your Previous EmployersPlease list your previous employers, the dates you worked and the position you heldYour Previous EmployersComapnyPhoneSupervisorJob Title Add RemoveAddressFrom MM slash DD slash YYYY To MM slash DD slash YYYY ResponsibilitiesMay we contact your previous supervisor for a reference? Yes No Your Previous EmployersCompanyPhoneSupervisorJob title Add RemoveAddressFrom MM slash DD slash YYYY To MM slash DD slash YYYY ResponsibilitiesMay we contact your previous supervisor for a reference? Yes No CompanyPhoneSupervisorJob TitleAddressFrom MM slash DD slash YYYY To MM slash DD slash YYYY ResponsibilitiesMay we contact your previous supervisor for a reference? Yes No Military ServiceBranchFromToRank at dischargeType of dischargeIf other than honorable, explainDisclaimer and signatureI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. SignatureDate MM slash DD slash YYYY Criminal HistoryHave you ever been convicted of violating any law? (Please omit minor traffic violations.) Yes No If yes, please list conviction(s), date(s) and location(s). The presence of a criminal record is not an automatic rejection of the application. Certain types of convictions will eliminate you from servicing vulnerable elders in their home. I attest that the above-mentioned information is true and accurate to the best of my knowledge. I further give the agency permission to call any of my citied previous employers or reference candidate for information regarding my character, employment history work ethics. LocationDate MM slash DD slash YYYY Candidate SignatureDate MM slash DD slash YYYY EMERGENCY CONTACT INFORMATION- Please Print ClearlyNameRelationshipHome Phone NumberWork Phone NumberCell Phone NumberCrossway Homecare LLC has an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, religion, handicap or military status
