Nursing and Office Staff Application

Date of Application *

Month

Day

Year

Date Available to start *

Month

Day

Year

Personal Information

First Name *

Middle Name *

Last Name *

Street *

City *

State *

Zip Code *

Phone Number *

If you cannot be reached at above phone number, where may we contact you?

Name of Person *

Phone *

Employment Desired

Position(s) applied for *

Rate of pay expected $ *

How did you learn of this position? *

Would you work Full-Time? *

Yes

Would you work Part Time? *

Yes

Are you 18 yrs. of age or older? *

Yes

Were you previously employed by us? *

Yes

Are you employed now? *

Yes

May we contact your present employer? *

Yes

Education

High School

Name of School *

Location (City, State) *

Courses Taken *

Completed *

Yes

Date Completed

Month

Day

Year

Type of Degree or Certificate *

College

Name of School

Location (City, State)

Courses Taken

Completed

Yes

Date Completed

Month

Day

Year

Type of Degree or Certificate

Vocational/Business

Name of School

Location (City, State)

Courses Taken

Completed

Yes

Date Completed

Month

Day

Year

Type of Degree or Certificate

Professional Education

Name of School

Location (City, State)

Courses Taken

Completed

Yes

Date Completed

Month

Day

Year

Type of Degree or Certificate

Extracurricular activities while in school

Member of Professional Organization

Honors Received, Volunteer/Community Services/Other Qualifications related to the position applied for

Professional License/Certificates

Licence/Certificate 1

Type of License 1

Organization or State Issued 1

Date Issued 1

License Number 1

Licence/Certificate 2

Type of License 2

Organization or State Issued 2

Date Issued 2

License Number 2

Licence/Certificate 3

Type of License 3

Organization or State Issued 3

Date Issued 3

License Number 3

Licence/Certificate 4

Type of License 4

Organization or State Issued 4

Date Issued 4

License Number 4

Personal References (No Family members/relatives)

Reference 1

Name and Occupation 1 *

Address 1 *

Phone Number 1 *

Reference 2

Name and Occupation 2 *

Address 2 *

Phone Number 2 *

Reference 3

Name and Occupation 3 *

Address 3 *

Phone Number 3 *

Reference 4

Name and Occupation 4 *

Address 4 *

Phone Number 4 *

Reference 5

Name and Occupation 5 *

Address 5 *

Phone Number 5 *

Employment History

List last or present position first

Position 1

Name 1 *

Address 1 *

City/State/Zip 1 *

Phone 1 *

Fax 1 *

From 1 *

To 1 *

Starting 1 *

Ending 1 *

Position & Duties 1 *

Reason for Leaving 1 *

Position 2

Name 2

Address 2

City/State/Zip 2

Phone 2

Fax 2

From 2

To 2

Starting 2

Ending 2

Position & Duties 2

Reason for Leaving 2

Position 3

Name 3

Address 3

City/State/Zip 3

Phone 3

Fax 3

From 3

To 3

Starting 3

Ending 3

Position & Duties 3

Reason for Leaving 3

Position 4

Name 4

Address 4

City/State/Zip 4

Phone 4

Fax 4

From 4

To 4

Starting 4

Ending 4

Position & Duties 4

Reason for Leaving 4

Employment Understanding

This Institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used such discrimination.

I voluntarily give this Institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this Institution at such times and place as the Institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any mistreatment or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.

I understand that Sunshine’s hiring process is a multistep process and I am not considered an employee until all the steps of the hiring process are successfully completed including signing the employee handbook.

I agree with the statements above in the Employment Understanding section *

Yes

Signature (type name - required) *

Date *

Additional Information

Do you have a Registered Nurse License? *

Yes

Date Received

Do you have a LPN License? *

Yes

Date Received

Do you have a current CPR certification? *

Yes

Date Received

Do you have a valid Driver's License? *

Yes

Expiration Date

Have you had a physical in the last 6 months? *

Yes

Date

Have you had a TB test in the last year? *

Yes

Date

Please note if you are called in for an interview you will be asked to bring a copy of your TB and Physical at that time.

Do you have experience in the following: (Y/N)

Bed Bath

Shower

Lift/Hoyer

Slide Board

Use of wheelchairs

Catheter Care

Transfers

Med Reminders

Spoon Feeding

Cooking

Rolling Walkers

Seizures

HTN

Paraplegic

Quadriplegic

Amputee

Cancer

Alz/Dementia

Diabetes

Psych Disorder

TBI

Developmentally Disabled

Sunshine Criminal History and OIG Exclusion Policy

Indiana law prohibits employment of anyone by a Licensed Home Health Agency or Licensed Personal Service Agency, if that person’s national criminal history background check indicated that the person has been convicted of any of the following:

(1) Rape (IC 35-42-4-1)
(2) Criminal deviate conduct (IC 35-42-4-2)
(3) Exploitation of an endangered adult (IC 35-46-1-12)
(4) Failure to report battery, neglect, or exploitation of an endangered adult (IC 35-46-1-13)
(5) Theft (IC 35-43-4), if the conviction of theft occurred less than ten (10) years before the person’s employment application date
(6) A felony that is substantially equivalent to a felony listed IN:

(A) Subdivision (1) through (4); or
(B) Subdivision (5), if the conviction for theft occurred less than ten (10) years before the person’s employment application date;
For which the conviction was entered in another state.

Sunshine is required to run every applicant’s name through the Office of Inspector General’s Exclusion list. If you are on the exclusion list, Sunshine cannot offer you employment.

Have you ever been convicted of any of the following?

Rape *

Yes

Criminal Deviate conduct *

Yes

Exploitation of an endangered adult *

Yes

Failure to report battery, neglect, or exploitation of an endangered adult *

Yes

Theft and/or Conversion *

Yes

Year

Medicare/Medicaid Fraud *

Yes

Applicant Signature (type name - required) *

Date *

IF YOU ARE APPLYING FOR A FIELD POSITION, PLEASE COMPLETE THE FOLLOWING SECTIONS. IF YOU ARE APPLYING FOR AN OFFICE ONLY POSITION PLEASE SKIP THE POLICIES AND AVAILABILITY AND HOURS SECTIONS.

Policies

Please take the time to read, understand, and initial each of the following policies:

Name *

The field nurse position requires providing services in client’s homes. You must have reliable transportation to client’s homes and be willing to drive to the different client’s homes in the Fort Wayne/New Haven/Huntertown area.