* Required Information

Personal Data

Emergency Contact Information

Job Information

Certifications: Check all applicable certifications and enter expiration date:

Work Experience

List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Date Employed

Pay Rate / Salary


Date Employed

Pay Rate / Salary


Date Employed

Pay Rate / Salary

Additional Information


I understand that I must report all accidents to my immediate supervisor and to Andrew Home Healthcare Services, LLC. No MATTER HOW SLIGHT.

I also understand that I must wear all required personal protection equipment (PPE). The penalty for not wearing PPE is disciplinary action, up to and including termination.

ACKNOWLEDGMENT (Please read carefully)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and because for my immediate dismissal from employment.

I give Andrew Home Healthcare Services, LLC or Andrew Developmental Disabilities Services, LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Andrew Home Healthcare Services, LLC or Andrew Developmental Disabilities Services, LLC with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, Andrew Home Healthcare Services, LLC or Andrew Developmental Disabilities Services, LLC may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Andrew Home Healthcare Services, LLC, or Andrew Developmental Disabilities Services, LLC its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such Andrew Home Healthcare Services, LLC, or Andrew Developmental Disabilities Services, LLC I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Andrew Home Healthcare Services, LLC or Andrew Developmental Disabilities Services, LLC I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Andrew Home Healthcare Services, LLC, or Andrew Developmental Disabilities Services, LLC, at any time, can constitute a contract of employment. No representative or agent of Andrew Home Healthcare Services, LLC, or Andrew Developmental Disabilities Services, LLC, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment, I agree that my continued employment may be contingent on the results.

I understand that Andrew Home Healthcare Services, LLC or Andrew Developmental Disabilities Services, LLC is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies Andrew Home Healthcare Services, LLC or Andrew Developmental Disabilities Services, LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

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