EMPLOYMENT APPLICATION FORM

We appreciate your interest in A Brighter Future Healthcare Services, Inc. Each application will receive consideration. Should our vacancies meet your qualifications, you may be asked to come in for a personal interview. If your background does not fit our needs at the present time, your application will be held in our active files for six months.

We have committed ourselves to the recruitment, employment, training and promotion of employees solely on the basis of the individual's qualifications, without regard to race, color, religion, age, sex, disability, veteran status or national origin in compliance with Federal and State equal employment laws. Persons employed may be required to provide verification of information on this form.

We comply with the requirements of the Immigration Reform and Control Act of 1986. Therefore, you will be required to provide certain documents, which establish your identity and authorization to work. It is our policy that you will not be permitted to begin employment until you produce such documents for our review.
* = Required Information

Date DOB Social Security No.
Position applying for:
PCA CNA1 CNA2 LPN RN Other
Other position applying for:
Last Name * First Name * Middle *
Are you known to schools/past employers by another name?   NoYes
Other Name
Address * City * State * Zip *
How long have you lived there?
Email Address *
If less than 5 years, previous Address:
Address: City: State: Zip:
Telephone No.: Home:* () Cell/Pager:* ()
Emergency Contact: Name:* Phone Number:* ()
Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any restrictions? YesNo
If required for the position for which you are applying, do you have a current driver's license? YesNo
Driver License No.: State: Expiration Date:
Have you ever been involuntarily terminated or asked to resign from any position of employment? Yes No
If yes, please describe circumstances:
Have you ever been convicted of a felony? Yes No
 
If yes, please describe circumstances:
Gender MaleFemale
Ethnicity: Voluntary Survey American Indian or Alaskan Native Black (not of Hispanic origin)
Asian or Pacific Islander                  Hispanic
White (not of Hispanic origin)
Do you have any responsibilities or commitments that may prevent you from meeting work and attendance requirements? Yes No
If yes, explain:
Date you can start?    Salary Required
How did you hear about us Newspaper Aide Friend Flyer Advertisment Other
Other Sources:
Have you ever been employed by A Brighter Future YesNo
EMPLOYMENT: All sections must be complete, list former employers beginning with current first
1.Employer Name:  Job Title
Dates Employed From To  Starting Pay Ending Pay
Address City State Zip
Telephone ()  Supervisor Name:
Job Duties & Responsibilities
 
 Supervisor Title:
 Reason for Living:
 May we contact you?:YesNo
2.Employer Name:  Job Title
Dates Employed From To  Starting Pay Ending Pay
Address City State Zip
Telephone ()  Supervisor Name:
Job Duties & Responsibilities
 
 Supervisor Title:
 Reason for Living:
 May we contact you?:YesNo
Education
Name of School Name/ Address Year Attended Degree/Diploma Graduated/Major
High School Yes
No
College/University Yes
No
Trade School Yes
No
Do you have a professional license or certification?   YesNo
If yes, please list:
Is it valid for North Carolina?   YesNo
If no, what State?:
License/Certification:
Has your license ever been revoked or suspended?   YesNo
If yes, please explain cicumstances:
List other information pertinent to the employment you are seeking?
REFERENCES: Please provide 2 business/ 2 personal references
Name Title Address/City/State/Zip Telephone
Applicant Signature:
Date:

In completing an application for employment with A Brighter Future Healthcare Services, Inc.,
I understand and acknowledge the following:
The information given by me on this application is true in all respects and I have not failed to disclose information, which A Brighter Future Healthcare Services, Inc. could consider relevant to its hiring decision. I understand that I may be refused employment, or if employed, terminated, if I give false or misleading information on my application or during the interview process.

A Brighter Future Healthcare Services, Inc. has my expressed authorization to thoroughly investigate my work, criminal record, or other related matters as may be necessary in arriving at an employment decision. This investigation may include personal interviews with current and former employers, references, neighbors, friend, and others with whom I may be acquainted. Further, I hereby authorize every person or entity contacted by A Brighter Future Healthcare Services Inc. to make any disclosure requested by A Brighter Future Healthcare Services, Inc., and release all records including employment records (my work and attendance records, the reason(s) for my leaving, my eligibility for rehire and my suitability for the position I am now seeking, medical records and school records. I encourage my current and former employers and all others contacted to provide complete responses to requests for information, including information, which is believed to be true but not documented. I realize some information may be complimentary and some may be critical.

I promise I will not bring any legal claims or actions against my current or former employers, others contacted or entities due to their responses to job reference requests. I recognize that there is also a North Carolina statute, which provides my employers with certain protections from such claims. I realize that no one is required to give a reference, so I make this commitment to encourage the free exchange of reference information.

I understand that if hired, I may occasionally be required to undergo a drug test to determine if I am involved in the improper or illegal use of drugs and/or alcohol. I further understand that failure to submit to a drug test will make me ineligible for employment. Further I understand that A Brighter Future Healthcare Services, Inc. reserves the right to require a medical examination of an employee at any time, except as may be prohibited by State or Federal Law.

I understand that, if employed, my employment is for no definite period of time, that I may terminate my employment at any time without cause, and that A Brighter Future Healthcare Services, Inc. may terminate or modify the relationship at any time without notice and without cause.

Should I become employed with A Brighter Future Healthcare Services, Inc., I agree to conform to the rules and regulations of the system and any modifications or amendments thereto.

I agree to hold confidential and protect all information regarding clients, former clients, employees, medical staff, etc. I understand that if employed, I have a specific obligation to ensure the confidential nature of clients privileged health information (PHI) and other data, which is delineated in the A Brighter Future Healthcare Services, Inc. Confidentiality Policy. I agree to abide by all policies in place at A Brighter Future Healthcare Services, Inc. to maintain confidentiality. I will not share any information with unauthorized persons. I understand that sharing of confidential information with unauthorized persons may be grounds for termination and may be punishable by fine or imprisonment under certain law and/or regulations.

I acknowledge and agree that if I fail to preserve or return any property and/or money that I may be entrusted with by A Brighter Future Healthcare Services, Inc., I hereby authorize A Brighter Future Healthcare Services, Inc. to deduct and withhold form my subsequent paychecks (or from other amounts due to me) the amount of money I have not repaid or returned and/or the cost of replacing the property I have failed to preserve or return, to the fullest extent that such deductions are permitted by law.
By signing this application I understand and acknowledge the above
Applicant Signature:
Date:

* Security Code