Circle Home - Job Application

Circle Home, Inc. is an equal opportunity employer.

All applicants and employees are considered for employment, advancement, development, and earnings based upon their skills, performance and, potential. No current or prospective employee is discriminated against because of race, religion, age, color, gender, sexual orientation, national origin, disability, military/veteran's status, and any other category protected by law. No question on this application is used for the purpose of limiting or excusing consideration of any applicant on a basis which is prohibited by local, state or federal law.

As you complete this application, please feel free to include in your experience/employment history, any verifiable work performed on a volunteer basis. The information you provide will help us to evaluate your qualifications, in accordance with current position requirements.

Massachusetts General Laws prohibit the use of lie detector tests as a condition of employment or continued employment. Circle Home, Inc. maintains full compliance with the law.

Please fill in or correct the highlighted fields.

Position Information

Position: *

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Contact Information

First name: * M.I:

Last name: *

Previous name:

Address: *

Address 2:

City: *

State: * Zipcode: *

Phone: * (include area code)

Email: *

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Education

High School	Years Completed	Course of Study	Year of Graduation
Name: Location:

College	Years Completed	Course of Study	Year of Graduation
Name: Location:

Other	Years Completed	Course of Study	Year of Graduation
Name: Location:

Add other

Other Education 2:

Name:

Location:

Add other

Other education 3:

Name:

Location:

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Computer Documentation Skills

Note: You may be tested on your computer skill level.

Familiarity with Computer Keyboard: No New User Experienced User

Familiarity with Windows-Based Software: No New User Experienced User

Software Experience: (list any that apply)

Typing speed: W.P.M Steno speed: W.P.M

Transcription skills? Yes

Medical Terminology? Yes

Other business machines you can operate:

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Professional Licenses and Certifications

License or Certification	Number	Expiration Date

	State National
License or Certification	Number	Expiration Date

	State National
License or Certification	Number	Expiration Date

	State National

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Work History

Start with present or most recent experience. List employers, volunteer activities, and/or military experience.

Employer 1:

Employer: Current position:

From: To:

Address:

Phone:

Job Title:

Summarize duties:

Immediate Supervisor:

Reason for Leaving:

Employer 2:

Employer:

From: To:

Address:

Phone:

Job Title:

Summarize duties:

Immediate Supervisor:

Reason for Leaving:

Add employer

Employer 3:

Employer: From:

From: To:

Address:

Phone:

Job Title:

Summarize duties:

Immediate Supervisor:

Reason for Leaving:

Add employer

Employer 4:

Employer:

From: To:

Address:

Phone:

Job Title:

Summarize duties:

Immediate Supervisor:

Reason for Leaving:

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Military Service

Branch of Service: Currently serving:

From: To:

Rank:

Special Schooling:

Duties:

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Reference Information

When listing references, please list at least one supervisory reference

Name: Years Known:

Position: (position or clinical license)

Relationship: (supervisor, colleague, friend, etc)

Address:

City:

State: Zipcode:

Phone:

Fax:

Other Reference Information:

Add reference

Reference 2:

Name: Years Known:

Position: (position or clinical license)

Relationship: (supervisor, colleague, friend, etc)

Address:

City:

State: Zipcode:

Phone:

Fax:

Other Reference Information:

Add reference

Reference 3:

Name: Years Known:

Position: (position or clinical license)

Relationship: (supervisor, colleague, friend, etc)

Address:

City:

State: Zipcode:

Phone:

Fax:

Other Reference Information:

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Other Information

Please feel free to include any other information you think would be helpful to us in considering you for employment, such as additional work experience, articles/books published, activities, accomplishments, etc.

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Statement of Accuracy & Release

I understand that any omission or any misleading or untrue statements or answers in this application may jeopardize my employment opportunities with Circle Home, Inc. or result in termination of my employment.

I authorize Circle Home, Inc. and Affiliates to investigate all references and to secure information about me from any person, company or organization without liability to such persons, company, organization or Circle Home, Inc. and Affiliates.

I understand that employment by Circle Home, Inc. is not for a definite term, and may be terminated at any time without prior notice.

I understand and acknowledge that all offers of employment shall be based on the following contingencies:

Appropriate evidence of meeting position qualifications;
Receipt of satisfactory references concerning the applicant from reliable sources;
Depending on the requirements of the position, satisfactory results of a medical examination and confirmation that the individual is free from communicable disease, including negative results from a test for tuberculosis;
Prior to any job offer, applicants must undergo a Criminal Offender Record Investigation through the Criminal History Systems Board, Executive Office of Public Safety of the Commonwealth of Massachusetts, as well as, an investigation through the Office of the Inspector General, U.S. Department of Health & Human Services; and,
Prior to any job offer, applicants for positions which involve direct patient care must undergo an investigation through the Massachusetts Nurse Aide Registry Division of Health Care Quality, Department of Public Health.

I understand that any job offer which may be made prior to the completion of any and/or all of these requirements is conditional.

I CERTIFY THAT THE ANSWERS GIVEN HEREIN OR PROVIDED BY MY RESUME ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Submit

Application For Employment

Position Information

Contact Information

Employment Information

Education

Other Education 2:

Other education 3:

Computer Documentation Skills

Professional Licenses and Certifications

Work History

Employer 1:

Employer 2:

Employer 3:

Employer 4:

Military Service

Reference Information

Other Information

Statement of Accuracy & Release

Forward " "

Application For Employment

Position Information

Contact Information

Employment Information

Education

Other Education 2:

Other education 3:

Computer Documentation Skills

Professional Licenses and Certifications

Work History

Employer 1:

Employer 2:

Employer 3:

Employer 4:

Military Service

Reference Information

Other Information

Statement of Accuracy & Release

Forward " document.write (document.title) "

Forward " "