* = Required Information

Personal Information

Yes No
Yes No
Yes No

Position Applied For

Full-Time Part-Time
Yes No
Yes No

Educational Background

High School

Yes No


Yes No

Trade Business/Correspondence Schools

Yes No

Employment History

Provide the following from your past and current employers, assignments or volunteer acivities - starting with the most recent.

Employer 1


Employer 2


Employer 3



Give the name of three business/work references, not related to you, whom you have known at least one year. If not applicable, list three school or presonal references that are not related to you.

Reference 1

Reference 2

Reference 3

Professional Licenses, Regulations and/or Certification

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time.

I give the employer the right to contact and obtain information from all references, employers, and educational institutions and 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 question on this application is used for the purposes 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 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 contact for employment for any specified period or definite duration.

I understand that 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 and Section 504 of the Rehabilitation Act.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

In consideration of my employment, I agree to conform to Essence Health Services, Inc. rules and regulation, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time by Essence Health Services, Inc.

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

Release of Information Authorization

I empower Essence Health Services, Inc and its agents to retrieve information from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the federal, state or county level, worker's compensation agencies or individual, relation to my past activities, to supply any and all information concerning my background, and release the same from any liability resulting in providing such information. That receipt may include, but is not limited to academic, residential, achievement, job performance, attendance, litigation, personal history, credit reports, driving history, disciplinary and conviction records.

By my signature below, I hereby release any individual or institution, including its officers, employees or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at the time result to me, because of compliance with this authorization and request to release information or any attempt to comply with it.

I hereby certify that all the statements and answers set forth on the application form and/or my resume are true and complete to the best of my knowledge, and I understand that if subsequent to employment any such statements and/or answers are found false or that information has been omitted, such false statements and or omissions will be just cause for the termination of my employment.

I am in agreement that a copy of this authorization can be accepted with the same authority as the original, and that this release expires one year after the date of origination.

Five Year Ohio Residency

It is the policy of this Agency to comply with the Administrative Code of the state of Ohio as it applies to individuals applying to a home health agency. The agency will conduct a criminal records check on any applicant for a position providing direct care. FBI checks are required if you have not been a resident of Ohio in the last 5 years. Please provide all addresses for the last five years.

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