Brite Horizon Employment Application FormFirst Name *Last Name *Social Security NumberStreet AddressCityZIP / Postal CodeHome NumberCell Number *Email Address *What position are you applying for?What special qualifications do you have?What office machines can you operate?Are you over 18?YesNoDate of BirthAre you a U.S. citizen or are you an alien authorized to work in the United States?YesNoHave you been convicted of a felony or a misdemeanor within the last 5 years?YesNoIf yes, please explain EDUCATION Elementary Dates AttendedName of SchoolCityDid you graduate?YesNoDegree Awarded High School Dates AttendedName of SchoolCityDid you graduate?YesNoDegree Awarded College Dates AttendedName of SchoolCityDid you graduate?YesNoDegree Awarded Other Dates AttendedName of SchoolCityDid you graduate?YesNoDegree Awarded Job Experience Have you had at least one year employment experience as a supervised home health aide, or nurse aide?YesNoIf yes, provide the following informationName and Address of Company Date:(Month/Year) FromToDescribe your job dutiesSalaryReason for leavingHas it been 24 months or more since you worked as a supervised home health aide, or nurse aide?YesNoIf yes, reason for the lapse Other Job Experience Name and Address of Company Date:(Month/Year) FromToList your dutiesSalaryReason for leavingName and Address of Company Date:(Month/Year) FromToList your dutiesSalaryReason for leavingAre you available to work?FullPart TimeSeasonalWhat shift(s) are you available to work?MorningAfternoonWhat days can you work?WeekdaysWeekendsDo you have a car or are you near a bus line?Have a carNear a bus lineDo you need special accommodations?YesNoHave you lived in the state of Ohio for five or more years?YesNoI understand and agree that I may be required to take one or more physical examinations, drug tests, and background checks as a condition of employment, I agree to consent to take such tests at such time as designated by the company and to release the company, its directors, officers, agents, or employees from any claim arising in connection with the use of these tests.AVAILABILITYPlease fill out the hours you are available to workMondayTuesdayWednesdayThursdayFridaySaturdaySundayEmployment Applicant Authorization to Release InformationI hereby authorize Brite Horizon, to investigate all references regarding my previous employment history and to secure all job related information about me. I hereby release from liability Brite Horizon and/ or its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.Applicant NameDatePERSONAL REFERENCE ONLY: Please provide all relevant employment information on the following individual who is applying for a position working with individuals who are elderly, children, and MR/DD.Instructions: Read each question in the left boxes and give a rating in one of the rating boxes corresponding to the applicant.CharacterExcellentGoodAverageFairProfessionalExcellentGoodAverageFairCourteousExcellentGoodAverageFairPunctualExcellentGoodAverageFairReliableExcellentGoodAverageFairAttendanceExcellentGoodAverageFairCooperationExcellentGoodAverageFairInitiativeExcellentGoodAverageFairResponseExcellentGoodAverageFairNameContact NumberDate Submit
