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Full Name *

Email *

Phone Number *

Address (Street, State, Zip Code) *

Applying in County *

Palm BeachMartinSt. LucieIndian RiverOkeechobee

Service *

Home HealthHome TherapyPrivate Duty NursingOther

Applying for Position *

Are you at least 18 years old and can you provide required proof of your eligibility to work? *

YesNo

Have you ever filed an application with Rehab Home Health before? *

YesNo

Have you ever been employed by Rehab Home Health before? *

YesNo

If you have previously filed an application or have ever been employed by RHH please give dates here:

Are you currently employed? *

YesNo

If currently employed, may we contact your current employer?

YesNoNot Applicable

Do you have friends and/or relatives currently working for Rehab Home Health? *

YesNo

If yes, please provide their name(s):

Can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? *

YesNo

If hired, on what date would you be available to work? *

What is your work availability?

Full-TimePart-TimePer Diem

Are you available to work on weekends? *

YesNo

Are you available for night shifts? *

YesNo

If hired, would you have a reliable means of transportation to and from work? (If applying for a field position, must have reliable vehicle) *

YesNo

Can you travel if position requires it? *

YesNo

Can you relocate if position requires? *

YesNo

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? * Conviction will not disqualify you from employment, however relevance of offense may be considered

YesNo

Are you capable of performing all the essential functions and all other duties of the job for which you’re applying? * Answer this question only if you have been informed about the requirements of the job.

YesNo

If no, please explain

Education *

High SchoolCollegeGraduate SchoolOther

High School (Name, Location)

College (Name, Location, Subjects Studied, Degree Earned)

Graduate School (Name, Location, Subjects Studied, Degree Earned)

Other Education or Specialized Training, Certificates or Licenses

Do you speak, write or read any other languages? If so, please list:

Start with your most recent job, and any job related military service assignments and/or volunteer activities for the past five years.

I am uploading a resume that includes all of the previous employment information below.

Cover Letter

Upload Resume (Please Include Previous 5 Years of Employment and References.)

Employer Name #1 *

Employer Address *

Employee Phone Number *

Dates (From-To)

Starting Position *

Starting Salary *

Ending Position *

Ending Salary *

Immediate Supervisor *

Duties *

Reason for leaving *

May we contact this employer? *

YesNo

Employer Name #2 *

Employer Address *

Employee Phone Number *

Dates (From-To)

Starting Position *

Starting Salary *

Ending Position *

Ending Salary *

Immediate Supervisor *

Duties *

Reason for leaving *

May we contact this employer? *

YesNo

Electronic Signature (Enter full name to sign) *