SOUTHEASTERN HEALTH SERVICES EMPLOYMENT APPLICATION
Desired Position      RN   LPN   HHA   PT   OT   ST   Other  
PERSONAL INFORMATION
Last Name
 First Name
 MI
Street Address
 Apt. No.
 City
 State
 Zip
Township
 Telephone Number
 Cell Number
Social Security Number
 E-mail Address
Languages Spoken
 Other Names for Education or Employment Purposes
Are you over the age of 18 yrs?
Yes  No		 Have you lived at the above address for 2 or more yrs?
Yes  No
Have you ever been convicted of or plead guilty to a crime? Yes   No      If Yes, provide details.
Have you ever had a Workers' Compensation claim? Yes   No      If Yes, provide details.
Have you ever worked for Southeastern Health Services before? Yes   No      If Yes, when?
Are you authorized to work in the United States? Yes   No      Are you a US citizen? Yes   No
How did you hear about Southeastern Health Services? SEHS Employee   Friend/Neighbor/Relative  
Newspaper Ad   Yellow Pages   Other  
Emergency Contact Name
 Relationship
 Phone Number
EDUCATION
Name of School
 Address/City/State
 Yr. Completed
 Degree Received
Name of School
 Address/City/State
 Yr. Completed
 Degree Received
PROFESSIONAL LICENSURE, CERTIFICATION, OR TRAINING
License
 State of Issue
 License Number
 Expiration Date
Certification
 State of Issue
 Certificate Number
 Expiration Date
  CPR Certified? Yes  No IV Certified? Yes  No
Training Type
 Where Obtained?
EMPLOYMENT INFORMATION
Please provide information on all employers for the last 5 years, starting with the most recent first.
Employer 1
Name of Employer
 Address
 City
 State
 Zip
Telephone Number
 Supervisor Name
 Supervisor Telephone Number
Position Held
 Employment Dates
 Ending Pay Rate (per hour)
Reason for Leaving
 Type of Position:
Full-Time   Part-Time   Per Diem  
Employer 2
Name of Employer
 Address
 City
 State
 Zip
Telephone Number
 Supervisor Name
 Supervisor Telephone Number
Position Held
 Employment Dates
 Ending Pay Rate (per hour)
Reason for Leaving
 Type of Position:
Full-Time   Part-Time   Per Diem  
Employer 3
Name of Employer
 Address
 City
 State
 Zip
Telephone Number
 Supervisor Name
 Supervisor Telephone Number
Position Held
 Employment Dates
 Ending Pay Rate (per hour)
Reason for Leaving
 Type of Position:
Full-Time   Part-Time   Per Diem  
PERSONAL REFERENCE
(no relatives)
Name
 Address
 City
 State
 Zip
Telephone Number
 Years Known?
ASSIGNMENT PREFERENCES
 
Keep in mind that Southeastern Health Services of PA, Inc. provides client services 24 hours a day, 7 days a week. Your flexibility is greatly appreciated.
 
Please check the days and time of day that you would like to work. Specify Actual Times  
SUNDAY Day   Evening   Night  to 
MONDAY Day   Evening   Night  to 
TUESDAY Day   Evening   Night  to 
WEDNESDAY Day   Evening   Night  to 
THURSDAY Day   Evening   Night  to 
FRIDAY Day   Evening   Night  to 
SATURDAY Day   Evening   Night  to 
How many hours per day are you willing to work? 
Are you interested in working?   Full-Time   Part-Time   Per Diem
(Every other weekend is required to work, if needed)
Patient Preference?   Pediatric   Geriatric
Are you willing to cover call-outs?   Yes   No
Are you willing to work holidays?   Yes   No
Do you have reliable transportation?   Yes   No
Do you have pet allergies?   Yes   No     If yes, please explain. 
Do you have other allergies that would make it difficult to go into a client's home?   Yes   No     If yes, please explain. 
Do you have a fear of pets?   Yes   No     If yes, please explain. 
Please note: If hired, Southeastern Health Services cannot cannot guarantee work or give assurance that you will only be
offered cases within the preferences that you gave. We use the information to try to accommodate your requests.