* = Required Information
Personal Information
Name:
Address
(DSP) Direct Support Professional CNA RN LPN Other
Full-Time (35+hrs) Part-Time (20+hrs) 12-Hours Shifts Shift or Split Shift
Live-In (Weekday) Live-In (Weekend Only) Other
Yes No
Yes No
In case of EMERGENCY notify
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Military Service
Yes No
N/A
Yes No
Education
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4
Yes No
* A High School Diploma or GED is required for this position
N/A

EDUCATION

Academic
Currently Attending
Yes No

Last Completed
Yes No

Vocational, Continuing Education
Currently Attending
Yes No

Last Completed
Yes No
Previous Employment
Date Month & Year

Date Month & Year

Date Month & Year
References
Give the names of three persons not related to you to whom you have known at least 1 year.



Applicant Name:
Equal Opportunity Information
State and Federal Government policy prohibits discrimination based on race, sex, color, creed, national origin, age or disability. Sex, age or absence of disability is a bona fide occupational qualifications in a small number of State jobs. The information request below will in no way affect as an applicant. Its sole use will be to see how well our recruitment efforts are reaching all segments of the population.
Male Female
Black White Hispanic Asian American Indian
DISABILITY
NOTE: The reporting of a disability is strictly VOLUNTARY
Disability means, with respect to any individual:
1) A physical or mental impairment that substantially limits one or more of the major life activities of such individual;
2) A record of such an impairment; or
3) Being regarded as having such an impairment (Americans with Disabilities Act of 1990).
Person’s with a disability who DO NOT WISH to report their disability should check item A. Information reported on this form will be kept confidential as required by State Law. Public disclosure of this information without your consent would be a violation of G.S. 126-27.
A None/Prefer NOT TO REPORT B Blind or Severely Visually Impaired
C Deaf or Severely Hearing Impaired D Loss of limited use of arms and/or hands
E Non-Ambulatory (use of wheelchair) F Respiratory Impairment
G Nervous System/Neurological Disorder H Health Concerns
I Intellectual Developmental Disability J Learning Disability
K Mental Health Concerns L Other
AUTHORIZATIONS
Please read carefully

TRUTHFULNESS OF APPLICATION: I certify that the facts set forth in this employment application are true and complete to the best of my knowledge.

I understand that the misrepresentation or omission of material facts may result in termination of my employment.

AUTHORIZATION TO INVESTIGATE: I authorize any of the persons or organization referenced in this application to give METNURSE Health Services, Inc. any and all information concerning my previous employment, education, or any other information they might have, with regard to any of the subjects covered by this application and release all such parties from the liability for any damage that may result from furnishing such information.

AT-WILL-EMPLOYMENT: I clearly understand and agree that if I am offered employment with METNURSE Health Services, Inc. it will be on an “At-Will” basis. Meaning that either I or METNURSE Health Services, Inc. may terminate the employment relationship at any time for any reason, with or without cause. I further understand that the “At-Will” nature of my employment with METNURSE Health Services, Inc is an aspect of employment that cannot be modified or changed, except by a written agreement signed by the chief executive officer of METNURSE Health Services, Inc. I further understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and METNURSE Health Services, Inc.

SEARCH OF PUBLIC RECORDS: Should a search of public records, including of an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment be conducted by internal personnel employed by METNURSE Health Services, Inc., I am entitled to copies of any such public records obtained by METNURSE Health Services, Inc. unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have checked the bot below.

EMPLOYMENT NOT GUARANTEED: I clearly understand that completing an Employment Application with METNURSE Health Services, Inc. does not guarantee employment. Employment begins the first physical day on the job.

I WAVE RECEIPT OF A COPY OF ANY PUBLIC RECORD DESCRIBED IN THE ABOVE SEARCH OF PUBLIC RECORDS PARAGRAPH.

Conditions of Employment
Please read carefully

Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or work sites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the METNURSE Health Services, Inc. service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the METNURSE Health Services, Inc. reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the METNURSE Health Services, Inc has the authority to make any assurances to the contrary.

I understand that I am responsible for paying for my own Local & National Criminal Background Check through COGENT Systems in the amount of $60.00 or less.

Yes No
Yes No

I give the METNURSE Health Services, Inc. the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the METNURSE Health Services, Inc. and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The METNURSE Health Services, Inc. is an Equal Opportunity METNURSE Health Services, Inc. The METNURSE Health Services, Inc does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, State or Federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation and failing settlement in mediation, to binding arbitration. Unless otherwise agreed a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

This application is current for 90 days. At the end of this time if I have not heard from the METNURSE Health Services, Inc. and still wish to be considered for employment, it will be necessary to fill out a new application.

Authorization to Release Information

I have applied for a position with METNURSE Health Services, Inc.

I have been requested to provide information for their use in reviewing my background and qualifications. Therefore, I hereby authorize the investigation of my past and present work, character, education, military and employment qualifications.

The release in any manner of all information by you is hereby authorized whether such information is of record or not, and I do hereby release all persons, agencies, firms, companies, etc., from any damages resulting from providing such information.

This authorization is valid for 90 days from my application date.
Please keep this copy of my release request for your files. Thank you.
Criminal Background
*For criminal background check, only
Jr Sr II III IV
Male Female
Black White Hispanic Asian American Indian
USA Other
Address

FOR OFFICE USE ONLY


GA Driver’s License State Issued ID Passport VISA Other

Yes No

Yes No N/A

Yes No