Work With Us

EMPLOYMENT

Nina's Health Care Services, LLC is now accepting applications online. Please complete the form to send your information or to submit your resume.

* = Required Information

Date

Name *

Social Security # (optional)

Present Address (Street / City / State / Zip) *

Permanent Address (Street / City / State / Zip)

Phone # *

If you are under 18, can you furnish a work permit?
Yes No

Have you lived in Ohio for at least 5 years?
Yes No

Employment desired
Full Time Part Time Temporary Seasonal

Position

Date you can start

Salary

Are you employed now?
Yes No

If so may we inquire of your present employer?
Yes No

Where

When

Ever applied for this company before?
Yes No

Are you on layoff and subject to recall?
Yes No

Will you travel if required?
Yes No

Will you relocate if job requires it?
Yes No

Will you work overtime if required?
Yes No

Are you able to meet the attendance requirements of this position?
Yes No

Have you ever been Bonded?
Yes No

Have you ever been convicted of a felony in the past 7 yrs?
Yes No

Have you lived in Ohio for the past 5 years?
Yes No

Such conviction may be relevant if job related but does not bar you from employment If yes explain

Drivers License Number

State

Education

Academic Currently Attending

Name and location of School

Number of years Completed

Did you Graduate?
Yes No

Subjects Studied

Academic Last Completed

Name and location of School

Number of years Completed

Did you Graduate?
Yes No

Subjects Studied

Trades of Business Currently Attending

Name and location of School

Number of years Completed

Did you Graduate?
Yes No

Subjects Studied

Trades of Business Last Completed

Name and location of School

Number of years Completed

Did you Graduate?
Yes No

Subjects Studied

Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with

Employment Application

Name and address of employer

Date Month and Year

Salary

Job

Reason for Leaving

Name and address of employer

Date Month and Year

Salary

Job

Reason for Leaving

Reference: Give the names of three persons not related to you to whom you have known at least 1 year.

Reference 1:

Name

Address

Phone

Years Acquired

Reference 2:

Name

Address

Phone

Years Acquired

Reference 3:

Name

Address

Phone

Years Acquired

List any foreign language(s) and check the box that best describes your skill level.

Language

Read and write
Yes No

Read and speak
Yes No

Speak Only
Yes No

Language

Read and write
Yes No

Read and speak
Yes No

Speak Only
Yes No

In case of Emergency notify

Name of Person to contact *

Address *

Relationship *

Phone *

Conditions of Employment - please read carefully

*
Reporting to work with impaired abilities or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksite, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

*
It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employers service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

*
I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

*
The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicants consideration for employment on a basis prohibited by local, State or Federal law.

*
Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

*
This application is current for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

Signature of Applicant *

Date *