4 ways to apply Online Application Form Upload Your Resume Download PDF Application Current Openings Step 1 of 4 25% Application for EmploymentWe are an EEO / AA EmployerNameFirst* Middle* Last* Date of Application* MM slash DD slash YYYY Present AddressAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneEmail* Enter Email Confirm Email Emergency ContactName Relationship PhonePosition Applying for RN LPN PT / OT / ST Home Health Aide Homemaker Companion Office / Administrative Type of Position Desired: Full Time Part Time Backup Shift Preference* Day Evening Night Weekend Any Are you willing to commute?* Yes No If yes, how far? Salary Desired* Date Available* MM slash DD slash YYYY Were you referred by a current Hiawatha HomeCare employee? If so, please indicateHave you previously been employed by Hiawatha HomeCare?* Yes No If yes when? Are you currently subject to a non - compete/non - solicitation agreement?* Yes No If yes, list employer name and date of agreement: Are you at least 18 years of age? (If no, you may be required to provide proof to work)* Yes No Are you eligible for employment in the U.S.?* Yes No As required by law, employment is contingent upon your ability to provide documented proof of citizenship or legal eligibility within 3 business days after hire. EMPLOYMENT EXPERIENCEIn order that we may verify prior experience, have you used another name in your previous jobs?* Yes No List other names used1.Complete in order with most recent employer first.Name Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSalary / Hourly Rate Supervisor Position Held Reason for leaving Can we contact as a reference Before job offer is made After job offer is made Please do not contact Could you be rehired for the position you last held? Yes No 2.Name Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSalary / Hourly Rate Supervisor Position Held Reason for leaving Can we contact as a reference Before job offer is made After job offer is made Please do not contact Could you be rehired for the position you last held? Yes No 3.Name Date From MM slash DD slash YYYY Date To MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSalary / Hourly Rate Supervisor Position Held Reason for leaving Can we contact as a reference Before job offer is made After job offer is made Please do not contact Could you be rehired for the position you last held? Yes No EducationSchool Name and Location - Diploma / DegreeHigh School or Equivalent Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Diploma / Degree College or University Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Diploma / Degree Other TrainingSpecial Skills / QualificationsAmerican Sign Language Yes Languages other than EnglishCertified Interpreter Yes Computer Skill Level Other Skills / ExperienceRN / LPNLicense/Certification/ ID # Issuing State/Company Expiration Date MM slash DD slash YYYY CNA / HHALicense/Certification/ ID # Issuing State/Company Expiration Date MM slash DD slash YYYY PT / OT / STLicense/Certification/ ID # Issuing State/Company Expiration Date MM slash DD slash YYYY Driver’ s LicenseLicense/Certification/ ID # Issuing State/Company Expiration Date MM slash DD slash YYYY Automobile Liability InsuranceLicense/Certification/ ID # Issuing State/Company Expiration Date MM slash DD slash YYYY Other Licenses or CertificationsLicense/Certification/ ID # Issuing State/Company Expiration Date MM slash DD slash YYYY Professional References1. Name Phone2. Name Phone3. Name PhonePLEASE READ BEFORE SIGNING1. I certify that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information submitted on this application will constitute grounds for denial or immediate dismissal from employment if I am hired. 2. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same. 3. I understand that Hiawatha HomeCare has a policy of at will employment where the employment relationship may be terminated without notice or cause by either myself or Hiawatha HomeCare. 4. If accepted for employment I agree to comply with all company policies and procedures, and to perform all duties assigned to me to the best of my ability. 5. This application is current and active for 1 year. At the conclusion of this time, if I have not had any contact from Hiawatha HomeCare and still wish to be considered for employment, it will be necessary for me to complete a new employment application. I Agree to the Above* Agree Signature* Reset signature Signature locked. Reset to sign again Date of submission* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Upload Your Resume Upload your Resume File*Max. file size: 50 MB.Click 'Choose File' button to select your resume file from your computer. *denotes required fieldEmail* Phone*HiddenDate Uploaded MM slash DD slash YYYY