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  • REGENCY HOME HEALTHCARE SERVICES, LLC
    APPLICATION FOR EMPLOYMENT

    Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veteran’s employment. We are an equal opportunity employer.
  • Your Information

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  • In Case of Emergency Notify

  • Employment Desired

  • Education

  • Name and location of SchoolYears attendedDate GraduatedDegree/Certification? 
  • Name and location of SchoolYears attendedDate GraduatedDegree/Certification? 
  • Name and location of SchoolYears attendedDate GraduatedDegree/Certification? 
  • Employment History

  • Employed from:Employed to:Name and address of employerSupervisors nameSalaryPositionReason for leaving 
  • References

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  • I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISMISSAL. FURTHER, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PREVIOUS NOTICE.

    I HEREBY AGREE THAT, AS A CONDITION OF EMPLOYMENT BY THE AGENCY, I WILL PROMPTLY INFORM THE AGENCY IN WRITING OF ANY CRIMINAL CONVICTIONS, IN ANY JURISDICTION (INCLUDING ALL PLEAS OF GUILTY), OTHER THAN MINOR TRAFFIC OFFENSES, OF WHICH I AM CONVICTED AFTER TODAY.

    BY PROVIDING MY NAME AND DATE BELOW I AGREE TO THE ABOVE DISCLAIMER.
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