Part 2 - Education

Part 3 - Employment

Employer Most Recent

Employer 2

Employer 3

Part 4 - Activities

Part 5 - Activities

Part 6 - Summary

NOTE: If you are tentatively offered a position with Three Rivers Home Health, you must satisfactorily complete a pre-employment health examination. As part of the selection process, you may be required to test for drugs and alcohol. Applicants who test positive for drugs or alcohol may not be eligible for employment. Applicants who refuse to submit to required drug and alcohol testing may not be considered for employment. A copy of your motor vehicle report will be requested from the appropriate agencies in various states, including the Georgia Department of Public Safety. Your privately owned vehicle, which you will be driving if employed, must pass a basic safety inspection. Also, Three Rivers may screen your financial and criminal history. As an employee, you may be required to submit to random drug screening at any time, at Three Rivers’ discretion.

APPLICANT’S STATEMENT: I certify the information herein is voluntarily provided and true and complete to the best of my knowledge. Also, I authorize investigation of all statements contained herein as may be necessary regarding consideration for employment. Further, I understand that any false statements or omissions may disqualify me from consideration and may be considered justification for dismissal if discovered at a later date.

SIGNATURE STATEMENT: By entering my name and the date below, I acknowledge that I am electronically signing this document, and I further acknowledge that I agree to all the terms and conditions set forth herein, and certify that all information supplied by me is true and correct.