Evacare Rehab Inc. Employment Application

1937 Pontius Ave. Los Angeles, CA 90025

Please complete the form, sign, and submit. A PDF copy will be emailed to HR.

Note: This form may contain sensitive personal information. Submit only over HTTPS.

Programs services and employment are available equally to everyone. The company does not discriminate on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, or sexual orientation of any person, in its employment practices. Please inform the Human Resources Department if you require reasonable accommodation to the application or interview.

Leave this field empty

General Section

Last Name

First Name

Position Applying For

Location (you may choose more than one)

Fairfield Fillmore Jackson Montclair Pasadena San Bernardino San Jose Southgate Home Health Traveling Nurse

Street Address

Apt

City

State

Postal

Country

Home Phone

Mobile Phone

Social Security #

Race

Can you, at the time of hire, submit verification of your legal right to work in the U.S.?

Add Note

Company will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of Article 9 of Chapter XVIII of the Los Angeles Municipal Code; Ordinance 184652.

Employment Desired

Date available to start

Rate of expected pay

How many hours per week are you able to work

Shift available

Any AM PM NOC

Employment desired

Full-Time Part-Time Per-Diem/On-Call Temporary

Weekend Availability

Saturday Sunday N/A

Education

High School

City/State

College / Vocational

City/State

Other / Certifications / Notes

Previous Employment (Begin With The Most Recent Position)

Employer 1

From

Position(s) held

Company

Phone

Address

Supervisor

Title

May we contact this employer?

Responsibilities

Reason for leaving

Employer 2

From

Position(s) held

Company

Phone

Address

Supervisor

Title

May we contact this employer?

Responsibilities

Reason for leaving

Employer 3

From

Position(s) held

Company

Phone

Address

Supervisor

Title

May we contact this employer?

Responsibilities

Reason for leaving

Professional References

Reference 1

Name

Relationship

Phone

Reference 2

Name

Relationship

Phone

Reference 3

Name

Relationship

Phone

Authorization

I, , hereby authorize Evacare Rehab Inc. and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, adult criminal or police records, and motor vehicle records to confirm the information in my application.

I release Evacare Rehab Inc. and its agents and any person or entity that provides information pursuant to this authorization from any and all liabilities, claims, or lawsuits regarding the information obtained.

Full Name (Printed)

Date

Signature (draw below)

Human check

To help prevent spam, please answer: 5 + 6 = ?