Abbott Home Care Online Application for Employment
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We encourage you to complete our application if you are interested in employment with one of the nation's top providers.
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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.
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Personal Information ------------------------------------------------------------------------------------------------------------
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Last Name: First Name: Middle Initial (If applicable):
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Street Address: City: State: Zip Code:
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Primary Phone Number: Secondary Phone Number: Email Address:
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If you are under 18 years of age, do you have a work permit?
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Yes
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No
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Not Applicable
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If not a U.S. citizen, do you have the right to remain permanently and work in the U.S.A?
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Yes
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No
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Not Applicable
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Have you ever been convicted of a felony?
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Yes
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No
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Employment Desired ------------------------------------------------------------------------------------------------------------
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Position applied for:
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Home Health Aide
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Office/Clerical
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LPN
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RN/Case Manager
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Other:
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Shift(s) you can work:
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Day
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Evening
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Either/Both
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Hours desired:
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Full-time
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Part-time
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Temporary
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How did you learn of this opening?
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Date you can start (MM/DD/YY) :
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Have you ever applied with this company before?
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Yes
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No
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When:
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Have you ever worked for this company before?
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Yes
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No
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When:
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Supervisor:
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Reason for leaving:
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Education ----------------------------------------------------------------------------------------------------------------------------
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Highest grade completed:
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Years in college:
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Name and location of last school attended:
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Vocation of trade training:
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Extracurricular activities while in school:
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Area of specialization or major interest:
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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:
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References --------------------------------------------------------------------------------------------------------------------------
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List (3) persons who know you well. Please do not include relatives or former employers.
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Name: Address: Phone Number: Yrs. Acquainted with you:
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Former Employers ----------------------------------------------------------------------------------------------------------------
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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.
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Dates Employed: Name/Phone Number Name of Supervisor: Position(s) held: From When to When? Employer's Information
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May we contact your present employer at this time?
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Yes
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No
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Employment Understanding (Please read and type your full legal name below if you are in agreement.
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* 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.
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Applicant's Signature (Typed name):
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Today's Date (MM/DD/YY):
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Click here to return to our home without submitting the application.
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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.
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