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Please fill out and submit the form below.
You may also print and fax this form.


Pre- Application Form

First Name:
Middle Name:
Last Name:
   
Street Address:
Apartment #:
City:
State:
Zip:
   
Email:
Phone:
Cell/Pager/Other:

 

Employment History:

From:
To:
Employer:
Job Title:
Phone:

From:
To:
Employer:
Job Title:
Phone:

From:
To:
Employer:
Job Title:
Phone:

Are you legally eligible for employment in this country?
Yes No

Nursing License #:
Expiration Date #:


Availability: (check all that apply)
Sunday: AM PM
Monday: AM PM
Tuesday: AM PM
Wednesday: AM PM
Thursday: AM PM
Friday: AM PM
Saturday: AM PM

Length of Shift: 4 Hours
  8 Hours
  10 Hours
  12 Hours

I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM THE EMPLOYER'S SERVICE, WHEREVER IT IS DISCOVERED.

I GIVE THE EMPLOYER THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYERS, EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION CONTAINED IN THIS APPLICATION. I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND ITS REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION.

THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTIONS ON THIS APPLICATION ARE USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE OR FEDERAL LAW.

IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER, HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER.

I UNDERSTAND IT IS THIS COMPANY'S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITY BECAUSE OF THAT PERSON'S NEED FOR A REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA.

I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.



You may also print and fax this form.


 

 


Current Job Opportunities

Registered  Nurses

Licensed Vocational Nurses

Physical Therapists

Speech and Language Pathologists

Home Health Aides

Homemaker/Companion

 
East West Home Care 16429 Berwyn Rd, Cerritos, CA 90703
Toll Free: 888-301-8111 Phone: 562-207-6970 Fax: 562-207-6981 E-mail: info@ewhomecare.com
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2007