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    Position Type:*








    Emergency Contact Name:*

    Have you ever been employed by Pristine Home Health Care before?*

    Date*

    Have you ever filed an application with Pristine Home Health Care before?*

    Are you of 18 years or older?*:
    Are you a U.S. citizen?*:
    Are you currently employed?*:
    May we contact your present employer?:

    Work Availability:

    Work Availability:

    Days of the Week:
    Live-In:
    Shifts:
    Do you have a car?
    Do you use public transportation?

    Licensure/Certification:

    (Please check which applies)

    Licensure:

    Certification:






    Carrier Name & Address:

    Do you speak, read and understand English:
    Indicate what foreign languages you speak, read, and/ write:

    Previous Employment:

    (Please include name, address, telephone number, position held: (work experience/ title/ department) and dates, supervisor’s names & titles, along with reason for leaving employer.) Please include your last position held and at least one year of prior work history.


    reason for leaving employer:


    reason for leaving employer:


    reason for leaving employer:

    Please explain in detail any periods of unemployment:

    1st Professional References:


    2nd Professional References:


    3rd Professional References:


    Education: School & Address | Did you graduate? | Type: Diploma/Degree/Certification | Dates attended





    Special skills and qualifications:

    Why are you interested in this position?

    State any prior work experience you possess that relates directly to the position that you are applying for:

    Upload your Resume:

    Upload your Physical ID:

    Upload 2 ID’s:

    Upload your NJ home health aide license:

    -
    As the applicant, I hereby authorize Pristine Home Health Care may request and receive, within one year of the date of my signing this application, any and all pertinent information concerning my prior employment and its termination, including reasons for such termination from all prior employers. I understand that all references listed above may be contacted in addition to past employers and educational institutions. I give permission for Pristine Home Health Care to contact my current employer for a reference.

    I certify that answers given are true. I give the agency authorization to complete an investigation of my statements and for a criminal background check to be completed. False or misleading information may result in my discharge. I understand I am required to abide by the rules and regulations of the agency.

    I further understand that if I am hired, I can be terminated, with or without cause and with or without notice. I agree to have my picture taken for identification purposes and to submit to drug screening tests, upon request, with or without cause.

    I understand that if I am applying for a DSP Position, I give the agency authorization to send me for fingerprinting (separate background check for the DHS), to conduct a central registry check, drug screening, and CARI check, to meet DHS standards.

    I also understand that the agency is an Equal Opportunity Employer, and all applicants are considered for all positions without regard to race, color, religion, sex, national origin, age or marital status.