* = Required Information

Sun Mon Tue Wed
Thu Fri Sat
YesNo

EMPLOYMENT HISTORY:
List all previous employers, beginning with your most recent employer. Please include all requested information on an additional page if necessary, labeled with your name and social security number.

Duties and Responsibilities
Reason for Leaving
VoluntaryInvoluntary
YesNo

Duties and Responsibilities
Reason for Leaving
VoluntaryInvoluntary
YesNo

Duties and Responsibilities
Reason for Leaving
VoluntaryInvoluntary
YesNo

Duties and Responsibilities
Reason for Leaving
VoluntaryInvoluntary
YesNo

Duties and Responsibilities
Reason for Leaving
VoluntaryInvoluntary
YesNo

General Employment Question

YesNo
YesNo
YesNo
YesNo

TO BE ANSWERED AT THE TIME OF INTERVIEW
Do you feel you can safely and efficiently perform the essential requirements of the job for which you are considered?

EDUCATIONAL HISTORY

High School
YesNo
List Diploma or Degree

College/University
YesNo
List Diploma or Degree

Other (Specify)
YesNo
List Diploma or Degree

PROFESSIONAL LICENSES, REGISTRATION & OR CERTIFICATION
Note: For any position requiring Registration, Licensure or Certification, ORIGINAL DOCUMENTS MUST BE PROVIDED
RegisteredLicensedCertified
RegistrationLicensureWill take boards



SPECIALIZED OFFICE OR MECHANICAL EXPERIENCE

Typing wpm, Data Entry, Medical Transcription, Shorthand/Dictaphone, Computer Skills.

List of office machines or mechanical equipment you are capable of using
YesNo
List any other experiences, skills or qualifications, which you want to describe (include software application for which you would rate yourself competent)

EMPLOYMENT ACKNOWLEDGEMENT
I understand that any false statement or material omissions made as part of this application will disqualify me from further consideration for employment and, if discovered later, will be grounds for discharge. I also understand that any offer of employment is contingent upon the results of pre-employment medical examination, drug screen, criminal background check and reference check. I authorize my former employers to release all information concerning my employment. I further authorize the release of any such information during or after my employment, without any prior notification. This authorization releases the aforesaid parties and Corlan Home Health, Inc. (CHH Inc) from any Liability for the collection and reporting of information.

Corlan Home Health, Inc. does not discriminate in hiring or employing on the basis of sex, color, mental status, religion, sexual orientation, national origin, age, disability, military status or any other protected category. No question on this application is intended to secure information to be used such discrimination.

I understand that if' am employed by CHH Inc., my employment is "at will" and may be terminated by me or by HHC Inc., at any time with or without cause, for any reason. No one other than the President of CHH Inc., has the authority to enter into an agreement contrary to the foregoing and any such agreement must be in writing and signed by both the President and me.