(Toll-Free) (1-800) 655-3666

Bright Horizons Home Health Services, Inc.

10511 S. Western Ave.

Los Angeles, CA 90047

Application Form

Applicants Information

Name


(last)	(first)	(MI)

Date

Address

street Address


apartment/Unit no.	city


state	Zip code

Phone

( )

Email Address :

Date available :

Social Security No.

Desired Salary:

Position Applied for :

Full time Work ?	Yes No
Part time work ?	Yes No
Per-diem work?	Yes No
If applying for temporary work, during what period of time?
What days and hours are you available for work?
Are you available evenings?	Yes No
Are you available on weekends?	Yes No
Would you be available to work overtime, if necessary?	Yes No
If hired, on what date can you start work?
Are you a citizen of the United States?	Yes No
If no, are you authorized to work in the U.S.?	Yes No
Have you ever been convicted of a felony?	Yes No
If yes, explain:
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Personal Information

Have you ever applied to or worked for Bright Horizons before?	Yes No
If yes when?
Do you have friends or relatives working for Bright Horizons?	Yes No
If yes, state name/relationship:
If hired, would you have a reliable means of transportation to and from work?	Yes No
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?	Yes No
If no, describe the functions that cannot be performed:
(Note: We comply with the ADA and consider reasonable accommodation measures that may necessary for eligible applicants / employees to perform essential functions. Hire may be subject to passing a medical examination, and skill and agility test.)
Are you currently employed?	Yes No
If so, may we contact your current employer?	Yes No

Education

High School :		Address :
From :		To:
Did you Graduate?		Yes No
Degree:

College:		Address :
From :		To:
Did you Graduate?		Yes No
Degree:

Other:		Address :
From :		To:
Did you Graduate?		Yes No
Degree:

Qualification

Registered Nurse (RN)

Licensed Vocational Nurse (LVN)

Certified Home Health Aide Experienced

MSW

Clerk

Other

BCLS/CPR

PALS

WOUND

Abilities (Check all conditions you have experience/knowledge with):

Straight Catheter	Blood Pressure	Tracheotomy Care
Colostomy Bag	Insulin Injection	Wound Vac
G or N/G Tube	Paralyzed	Diabetes Sugar Testing
Catheter Male	Nebulizer	Hoyer Lift
Catheter Female	Oxygen	Cancer
Spinal Cord Injury	Computers	Heplock
Heart Condition	Stroke	Wound Care
Diabetes	Suctioning	Enemas
Bedsore	Ventilator	IV Insertion

What other specialties / experience do you have (IV Certified, Phlebotomist, Wound Vac etc.?
What other things would you like us to know about you?

References

Please list three professional references.

Full Name	Relationship
Company	Phone	( )
Address

Full Name	Relationship
Company	Phone	( )
Address

Full Name	Relationship
Company	Phone	( )
Address

Previous Employment

Company		Phone	( )
Address			Supervisor
Job Title
Start Salary	$	Ending salary	$
Responsibilities
From			To
Reason for leaving :

May we contact your previous supervisor for a reference? Yes No

Company		Phone	( )
Address			Supervisor
Job Title
Start Salary	$	Ending salary	$
Responsibilities
From			To
Reason for leaving :

May we contact your previous supervisor for a reference? Yes No

Company		Phone	( )
Address			supervisor
Job Title
Start Salary	$	Ending salary	$
Responsibilities
From			To
Reason for leaving :

May we contact your previous supervisor for a reference? Yes No

Military Service

Branch	From	To
Rank at discharge
Type of discharge
If other than honorable than explain.

Requirements

	Application.
	Physical Exam - Persormed within six months prior to application or before 14 days after employment.
	Social Security.
	Professional License or Certificate.
	Current CPR card .
	Auto Insurance.
	Employer Liability (Recommended)
	Negative Mantoux (PPD) or chest x-ray performed within six months prior to application
	Driver's License

Disclaimer and Signature

We are an equal opportunity employer, dedicated to policy of nondiscrimination in employment
on any basis including race, color, age, sex, religion or national origin.

I hereby certify that I Have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application, or on any document used for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize Bright Horizons to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further authorize the referenced I have listed to disclose to Bright Horizons any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or Bright Horizons, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Bright Horizons designated representative.

signature :: Date :
By clicking submit you hereby give Bright Horizons Home Health Services, Inc. or their representative, the right to do a background & criminal check. I
further certify that I, the undersigned applicant, have personally completed this application.

AFHOLA
Association of
Freestanding Home Health
Agency Owners of Los Angeles