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Apply for PT

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Summary
Title:PT
ID:72257
Department:Annandale
Resume
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Opt-In Confirmation
I authorize recruiters from Professional Healthcare Resources, Inc. to send text messages from 8883398229 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Employment Application
INSTRUCTIONS FOR APPLICANT
  1. You must fully and accurately complete the Application for Employment. Incomplete applications will not be considered. Professional Healthcare Resources may use the information given in this application to investigate your previous employment and background.
  2. If you are hired, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States. PHRI participates with E‐Verify.
  3. Professional Healthcare Resources conducts criminal records checks. Convictions will not necessarily disqualify you from employment. However, non‐disclosure of such on this application will disqualify you from employment.
We consider applicants for all positions without regard to race, color, religion, creed, national origin, age, disability, sexual orientation, marital status, or any other legally protected status
If completing on paper, please print clearly in ink. If completing on computer, please tab between data fields.
If you have been at your current address less than three years, please list all residences for the past three years. If necessary, attach a separate sheet.
Yes   No
  
  
  
  
  
  
  
  
  
  
  
  
Yes   No
Yes   No
If yes, and you are not a U.S. citizen, please provide the number of your Resident Alien or Work Authorization Card.
Yes   No
EMPLOYMENT HISTORY
List present employer first. Include any job‐related, military service assignments, and volunteer activities. You may exclude organizations which indicate race, color, religion, sexual orientation, national origin, disabilities, or other protected status. You may include additional employment on separate sheet.
Yes   No
Full‐time   Part‐time   PRN
Salary   Hourly   Per Visit
Yes   No
Full‐time   Part‐time   PRN
Salary   Hourly   Per Visit
Yes   No
Full‐time   Part‐time   PRN
Salary   Hourly   Per Visit
Experience in (years/months):
PROFESSIONAL LICENSURE / CERTIFICATION
Yes   No
Yes   No
Yes   No
EDUCATION
Yes   No
1   2   3   4
Yes   No
1   2   3   4
Yes   No
1   2   3   4
Yes   No
1   2   3   4
Yes   No
1   2   3   4
DRIVER'S LICENSE VERIFICATION
Yes   No
Yes   No
Yes   No
Yes   No
REFERRAL SOURCE
Advertisement   Walk‐in   Referral   Company Website   Publication   Other
Yes   No
Yes   No
Yes   No
Yes   No
RESTRICTIONS
Yes   No
CRIMINAL CONVICTIONS
As a provider of home healthcare services, Professional Healthcare Resources is required to conduct criminal background checks. Conviction of a crime may not disqualify you from employment. However, non‐disclosure of a conviction will automatically preclude you from employment.
Yes   No
Yes   No
AUTHORIZATION FOR RELEASE OF INFORMATION
I CERTIFY that the information contained in this application is true, complete, and correct to the best of my knowledge and belief.
I UNDERSTAND that any falsification or omission of information may be cause for my immediate dismissal or rejection of this application. I understand that all statements made in this application may be verified.
I AUTHORIZE Professional Healthcare Resources, at the time of my application for employment, to obtain information from any source as to my education, work experience, character, and competence to perform the job functions and duties of the position for which I am applying. I understand that this information will be evaluated to determine whether a conditional offer of employment should be made.
In the event that I am employed, such employment will be at‐will, and I understand that Professional Healthcare Resources may terminate my employment at any time without liability for wages or salary except that which is earned at the date of termination. Neither I, nor Professional Healthcare Resources, have agreed to any specific period of employment nor any specific pay or benefits unless otherwise set forth in a separate contract.
In addition, if accepted for employment, I hereby agree to abide by all the rules and policies of Professional Healthcare Resources.
EQUAL EMPLOYMENT OPPORTUNITY
Professional Healthcare Resources, Inc. does not discriminate in hiring or employment because of race, color, religion, creed, age, sex, veteran status, sexual orientation, disability, national origin, or ancestry. This Policy includes but is not limited to all decisions made on promotions, transfers, demotions, reductions in force, discipline, recruiting, compensation, benefits, training, education, or any other terms or conditions of employment.
VOLUNTARY APPLICANT DATA
The completion of this information is voluntary. If you do not wish to provide us the information you may separate this page from your application.
Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, sexual orientation, marital or Veteran status, medical condition or disability.
Government agencies required periodic reports on sex, ethnic, disabled and veteran status of applicants. As an employer we comply with government regulations.
To help us comply with government record keeping, reporting or other legal requirements, please fill out the information on this page. This data is not a part of the application process and will be kept in a separate confidential file.
We appreciate your cooperation. Providing this information is voluntary. Refusal to provide this information will NOT affect your consideration for employment in any way.
Check if any of the following are applicable
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
White   Asian   Alaskan Native   Black   Hispanic   American Indian   Pacific Islander   Other
Male   Female   Choose Not to Identify
Sworn Statement
Sworn Statement
Convictions will not necessarily disqualify applicantsfrom employment with Professional Healthcare Resources, Inc.
Information provided on this form will be utilized to conduct a criminal records check.
I have not been convicted of any criminal charges, nor do I have any criminal charges pending within or without MD, DC, or VA.
I have been convicted of the criminal charge(s) of:
Employment Verification

Employment Verification

I AUTHORIZE Professional Healthcare Resources, at the time of my application for employment, to obtain information from any appropriate source as to my work experience, character, and competence to perform the job functions and duties of the position for which I am applying.
DIST   BETH   LANH   ANNA   BALT   CORP
Previous Employment
Full‐time   Part‐time   PRN
Salary   Hourly   Per Visit

Employment Verification

I AUTHORIZE Professional Healthcare Resources, at the time of my application for employment, to obtain information from any appropriate source as to my work experience, character, and competence to perform the job functions and duties of the position for which I am applying.
DIST   BETH   LANH   ANNA   BALT   CORP
Previous Employment
Full‐time   Part‐time   PRN
Salary   Hourly   Per Visit
WOTC 8850
Form 8850 (Rev. March 2016) Department of the Treasury Internal Revenue Service
Pre-Screening Notice and Certification Request for
the Work Opportunity Credit
Information about Form 8850 and its seperate instructions is at www.irs.gov/form8850.
OMB No. 1545-1500
Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.
Your Name
*
Social security number
*
Street address where you live
*
City or town, state, and ZIP code
*
County
*
If you are under age 40, enter your date of birth (month, day, year)
1
2
  • I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
  • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
  • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
  • I am at least age 18 but not age 40 or older and I am a member of a family that:
    1. Received SNAP benefits (food stamps) for the past 6 months; or
    2. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
  • During the past year, I was convicted of a felony or released from prison for a felony.
  • I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
  • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
3
4
5
6
  • Received TANF payments for at least the past 18 months; or
  • Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
  • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
7
Signature - All Applicants Must Sign
Under penalties of perjuty, I delcare that I have the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.
Job applicant's signature
*
Date
*



For Employer's Use Only
If, based on the individual's age and home address, he or she is a member of group 4 or 6 (as described under Members of Targeted Groups in the seperate instructions), enter that group number (4 or 6)
Date applicant:
Under penalties of perjury, I declare that the applicant provided the information on this form on or before the day a job was offered to the applicant and that the information I have furnished is, to the best of my knowledge, true, correct, and complete. Based on the information the job applicant furnished on page 1, I believe the individual is a member of a targeted group. I hereby request a certification that the individual is a member of a targeted group.
Employer's Signature
Title
Date
Privacy Act and Paperwork Reduction Act Notice

Section references are to the Internal Revenue Code.

Section 51(d)(13) permits a prospective employer to request the applicant to complete this form and give it to the prospective employer. The information will be used by the employer to complete the employer's federal tax return. Completion of this form is voluntary and may assist members of targeted groups in securing employment. Routine uses of this form include giving it to the state workforce agency (SWA), which will contact appropriate sources to confirm that the applicant is a member of a targeted group. This form may also be given to the Internal Revenue Service for administration of the Internal Revenue laws, to the Department of Justice for civil and

criminal litigation, to the Department of Labor for oversight of the certifications performed by the SWA, and to cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Recordkeeping . . . 6 hr., 27 min.

Learning about the law or the form . . . 24 min.

Preparing and sending this form to the SWA . . . 31 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can send us comments from www.irs.gov/formspubs. Click on "œMore Information" and then on "œGive us feedback." Or you can send your comments to:

Internal Revenue Service Tax Forms and Publications 1111 Constitution Ave. NW, IR-6526 Washington, DC 20224

Do not send this form to this address. Instead, see When and Where To File in the separate instructions.
Form 8850 (Rev. 3-2016)
VEVRAA Pre-Offer Self-Identification Form
Invitation to Self-Identify

VETERANS
This company is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:
  • A "disabled veteran" is one of the following:
    • A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
    • A person who was discharged or released from active duty because of a service-connected disability.
  • A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
  • An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
  • An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA - the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

I identify as one or more of the classifications of Protected Veteran listed above.
I am not a Protected Veteran

2020 - Voluntary Self-Identification of Disability CC-305

Voluntary Self-Identification of Disability

Form CC-305
Page 1 of 1
OMB Control Number 1250-0005
Expires 05/31/2023
Name:
Employee ID:
(if applicable)
Date:

Why are you being asked to complete this form?

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified peoplewith disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individualswith disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability. Because a person may become disabled at any time, we ask all of our employees to update their information at least every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:
  • Autism
  • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
  • Blind or low vision
  • Cancer
  • Cardiovascular or heart disease
  • Celiac disease
  • Cerebral palsy
  • Deaf or hard of hearing
  • Depression or anxiety
  • Diabetes
  • Epilepsy
  • Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
  • Intellectual disability
  • Missing limbs or partially missing limbs
  • Nervous system condition for example, migraine headaches, Parkinson’s disease, or Multiple sclerosis (MS)
  • Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

Please check one of the boxes below:

Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
I Don’t Wish To Answer
 
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
 
For Employer Use Only
Employers may modify this section of the form as needed for recordkeeping purposes.

For example:
Job Title:
Date of Hire:
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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