Application

Online Application

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

High School *

Course of Study *

Last Year Completed *

Did You Graduate? *

Yes No

College *

Course of Study *

Last Year Completed *

Did You Graduate? *

Yes No

Other Education *

License/Certificate *

State Issued *

Expiration Date *

Number *

Status *

Active Inactve

License/Certificate *

State Issued *

Expiration Date *

Number *

Status *

Active Inactive

Employer Name *

Job Title/Duties *

Supervisor *

Reason For Leaving *

Supervisor's Number *

Work Type *

Full Time Part Time Per Diem

Pay *

Employer Name *

Job Title/Duties *

Employer Name *

Job Title/Duties *

Supervisor *

Reason For Leaving *

Supervisor *

Reason for Leaving *

Supervisor's Number *

Work Type *

Full Time Part Time Per Diem

Pay *

Supervisor's Number *

Work Type *

Full Time Part Time Per Diem

Pay *

If you are not a U.S. Citizen, are you legally authorized to work in the U.S.? *

Yes No Don't know

(If hired, you will be required to provide proof of your legal right to work)

Have you ever been sanctioned or disciplined by any state or federal authority or excluded from participation in the Medicare or Medi-Cal programs under Sec. 1128 of the Social Security Act? *

Yes No

If yes, explain *

References

Three former supervisors, managers or teachers other than relatives.

Name *

First

Last

Title *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name *

First

Last

Title *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name *

First

Last

Title *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Inland Home Health Providers, Inc. (IHHP) is committed to a policy of equal employment opportunity and considers all persons without regard to race, color, religion, age, sex, national origin, disability, marital status, veteran’s status, or any other legally protected classification as defined by city, state, and federal law.

Certification and Acknowledgment (Please read carefully and sign)

I certify that all of the information I have provided on this application and on any accompanying documents is true and correct. I understand that any false statements I have made herein on my failure to disclose requested information may disqualify me from consideration for employment or if employed may result in my termination.
I hereby authorize IHHP, its agents and employees to contact any reference provided by me during the application process, and I authorize all references all so contacted to release any information about me that they may have. I further authorize IHHP or its agents to perform an investigation of local, state and federal records relating to any criminal conviction I may have. I release IHHP, its agents, officers and employees and any reference contacted by IHHP from any and all liability that may result from any investigation or reference check.
I understand and acknowledge that I may be required to undergo a post-offer, pre-employment physical exam, and a post-offer, pre-placement drug screening and analysis for substance abuse. I understand that the result may to the extent permitted by law, result in the revocation of any offer of employment.
I understand and acknowledge that nothing contained in this application or in any interview which I may be granted is intended to create a contract of employment between IHHP and me. I further understand and acknowledge that if I am offered employment, I am free to terminate my employment at any time, for any reason, and the company retains the same right.

Type Name *

*Signature will be required when you come in.

Date *

Submit