Abbott Home Care
Online Application
for Employment
 We encourage you to complete
our application if you are
interested in employment with
one of the nation's top providers.
All information submitted with this form will be encrypted and
sent via a secure connection to protect the applicant's information.
Please answer all areas completely.
Personal Information ------------------------------------------------------------------------------------------------------------
Last Name:                      First Name:                                                Middle Initial (If applicable):
Street Address:                  City:                             State:                               Zip Code:
Primary Phone Number:                       Secondary Phone Number:                       Email Address:
If you are under 18 years of age, do you have a work permit?
Yes
No
 Not Applicable
If not a U.S. citizen, do you have the right to remain permanently and work in the U.S.A?
Yes
 No
 Not Applicable
Have you ever been convicted of a felony?
Yes
 No
Employment Desired ------------------------------------------------------------------------------------------------------------
Position applied for:
 Home Health Aide
 Office/Clerical
LPN
 RN/Case Manager
 Other:
Shift(s) you can work:
 Day
 Evening
 Either/Both
Hours desired:
 Full-time
 Part-time
 Temporary
How did you learn of this opening?
Date you can start (MM/DD/YY) :
Have you ever applied with this company before?
 Yes
 No
 When:
Have you ever worked for this company before?
 Yes
 No
 When:
Supervisor:
 Reason for leaving:
Education ----------------------------------------------------------------------------------------------------------------------------
Highest grade completed:
 Years in college:
Name and location of last school attended:
Vocation of trade training:
Extracurricular activities while in school:
Area of specialization or major interest:
Professional organization memberships, honors received, volunteer or community service, or other
qualifications you have which you feel are related to the position for which you are applying:
References --------------------------------------------------------------------------------------------------------------------------
List (3) persons who know you well.  Please do not include relatives or former employers.
Name:                        Address:                         Phone Number:          Yrs. Acquainted with you:
Former Employers ----------------------------------------------------------------------------------------------------------------
List below your work experience, starting with your most recent or last place of employment.  If you have not
previously held employment, please type N/A in the first line of boxes.
Dates Employed:             Name/Phone Number    Name of Supervisor:          Position(s) held:
From When to When?       Employer's Information
May we contact your present employer at this time?
 Yes
 No
Employment Understanding (Please read and type your full legal name below if you are in agreement.
* This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origins,
ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to the ability to perform the
work required.  No question in this application is intended to secure information to be used for 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 places as the institution shall designate.  I understand that an offer of employment may be
contingent on passing the physical examination which is related 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 misstatement 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 Abbott Home Care makes every attempt they are able to ensure that this information remains confidential.  I
realize that submitting information online carries certain risks.  I agree that Abbott Home Care and any parties related to Abbott in
the development and use of this online form shall not be held accountable if the information is obtained by outside sources in
any way through legal or illegal means (I.e. - hacking of the website).  I realize that I may obtain a copy of the application at one of
the offices if I choose not to take this risk.
Applicant's Signature (Typed name):
Today's Date (MM/DD/YY):
Click here to return to our home without submitting the application.
After you click Submit you might wish to print the confirmation page for your records.  Depending on your
browser settings, you might get a warning about the data being unencrypted.  If so, you must select continue
if you still desire to send the application.  Clicking cancel will discard all information without sending.