Professional Documents
Culture Documents
Name: Date:
Last First Middle
Address
Street City State/Province ZIP/Postal Code
Do you carry professional liability insurance? Yes No If yes, in what amount? _____________
Have you worked for Helping Individuals LLC(HILLC) before? Yes No
Have you ever been convicted, plead guilty or no contest to a crime (misdemeanor or felony? Yes No
Have you ever been disciplined by professional or state ethics or Licensing board? Yes No
Have you been in a car accident or recieved a moving violation in the last 3 months? Yes No
If hired as an independent contractor, will you agree to provide a Driver's record? Yes No
Updated 6/5/10
EDUCATIONAL BACKGROUND
List previous three (3) educational institutions attended, beginning with the most recent
Yes No
Yes No
Yes No
List all licenses, certificates, or speiclaized trainings you have related to the position you are applying for:
Yes No
Yes No
Have you recently tested (last 12 months) negative for tuberculosis (TB)? Yes No
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What was the best job you ever had and why?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
How will you be able to contribute to providing individuals with high quality care?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2
Updated 7/3/10
EMPLOYMENT BACKGROUND
Provide the fol lowing information beginning with the most recent employer.
Yes No Later
EMPLOYER TELEPHONE DATES SUMMARIZE THE TYPE OF WORK
EMPLOYED PERFORMED AND RESPONSIBILITIES
( ) FROM TO
ADDRESS
3
Updated 7/31/10
PROFESSIONAL REFERENCES
List name, relationship, years acquainted and phone number of three references (No relatives or personal friends please)
YEARS
NAME RELATIONSHIP PHONE NUMBER
ACQUAINTED
I certify that all the information I have provided is true, complete and correct.
I authorize HILLC to investigate all statements contatined on this application, I understand that any misrepresentation
or omission of facts cause for immediate disqualification and/or if engaged immediate dismissal.
I understand that if I am hired by HILLC, I will be required to provide a criminal background check, proof of identity and
legal authority to work in the United States, proof of certification or educational qualifications and a drivers record if
applicable.
This application does not in any way constitute a contract for employment or for the provision of services as
an independent contractor.
4
Updated 7/31/10