Employment Application — Nurses Care, Inc.

Position & Contact Information

Position applying for *

First name * Middle initial Last name * Date available to start

Cell phone * Home phone

Email address * Street address *

City * State * ZIP code * Salary / pay rate desired

Driver's license number License state

Are you authorized to work in the U.S. on an unrestricted basis? *

Yes No

How did you hear about us?

Education & Qualifications

High School / GED

School name & location Year completed

Completed?

Yes No

College / University

School name & location Degree

Graduated?

Yes No

Vocational / Technical / Other

School name & location Certificate

Graduated?

Yes No

Special skills / certifications / relevant experience

Professional References

Please provide at least two professional references.

Reference 1

Full name * City / State Phone number * Relationship

Reference 2

Full name * City / State Phone number * Relationship

Reference 3 (optional)

Full name City / State Phone number Relationship

Work History (most recent first)

Job 1

Job title * Company name & address From (MM/YY) To (MM/YY or “present”) Supervisor name & phone Salary (start / end) Ending salary Reason for leaving

May we contact this employer?

Yes No N/A

Key responsibilities & duties

Job 2 (optional)

Job title Company name & address From (MM/YY) To (MM/YY or “present”) Supervisor name & phone Salary (start / end) Ending salary Reason for leaving

May we contact this employer?

Yes No N/A

Key responsibilities & duties

Job 3 (optional)

Job title Company name & address From (MM/YY) To (MM/YY or “present”) Supervisor name & phone Salary (start / end) Ending salary Reason for leaving

May we contact this employer?

Yes No N/A

Key responsibilities & duties

Position Screening & Requirements

1) Do you have any previous involvement as a defendant in professional malpractice? *

Yes No

2) Have you ever had your professional license revoked, suspended, or disciplinary action taken? *

Yes No

3) Are you able to transfer up to 50 lbs? *

Yes No

4) Are there any problems or allergies with pets? *

Yes No

5) Do you have a valid Ohio Driver's License? *

Yes No

6) Do you have your own reliable transportation? *

Yes No

7) Do you have liability auto insurance of $100,000/person, $300,000/accident? *

Yes No

8) Are there any parts of the essential job functions/description that you cannot fulfill at this time? *

Yes No

Comprehensive Health & Medical Questionnaire

Please check any past or present medical conditions, surgeries, injuries, or chronic health diagnoses below. This information helps us evaluate job readiness and safety for both healthcare staff and patients.

If you checked any conditions above, please explain details, dates, surgeries, or ongoing care

Health & Job Fitness Declaration

Do you have any physical, mental, or medical condition that would prevent or impair you from performing the essential functions of the position applied for, with or without reasonable accommodation? *

Yes No

Background Screening Information

Ohio law requires a BCI (and if applicable FBI) criminal background check for all home health employees. This information is used only for that screening and is stored encrypted. Your Social Security number and date of birth are not collected here — we only ask for those after an offer of employment, in your secure onboarding portal.

Place of birth (city, state/country) * Maiden or other name(s) used

Address history

How long at your current address? If under 7 years, list previous addresses.

Time at current address

Previous address 1 How long? Previous address 2 How long?

Have you been convicted of or pled guilty to a crime in the last 7 years? *

Yes No

May we contact your present employer?

Yes No

I am a resident of Minnesota, California, or Oklahoma and would like a copy of the investigative report.

Certification & Signature

Applicant Certification

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if employed, false statements, omissions, or misrepresentations may result in dismissal. I authorize Nurses Care, Inc. to make an investigation of any facts set forth in this application and release the Employer from any liability. I acknowledge and understand that Nurses Care, Inc. is an ‘at-will’ employer.

I have read and agree to the certification above. *

Authorization & Consent for Release of Information

Read the full background screening consent

It is a condition of employment, and/or continued employment, that all applicants consent to and authorize a verification of the information submitted on their application or resume. This release and authorization acknowledges that Nurses Care, Inc. may now, or at any time while I am employed, conduct a verification of my education, employment history, credit history, and/or motor vehicle records; contact personal references; require that I provide a urine specimen or hair strands to be tested for the presence of drugs or alcohol; and receive any criminal history record information pertaining to me from any Federal, State or Local criminal justice agency. If an offer of employment has been made, I authorize review of my worker’s compensation claim history. I authorize persons, schools, current and former employers, and other organizations and agencies to provide Employment Screening Associates with all information that may be requested, and I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is as valid as the original. According to the Federal Fair Credit Reporting Act, I am entitled to know if employment was denied based on information obtained by my prospective employer, and to receive, upon written request, a disclosure of the public record information and of the nature and scope of the investigative report.

I authorize the background verification described above. *

Release of Background Check Results (BCI / FBI WEBCHECK)

Read the full release

I certify that I have given Nurses Care, Inc. permission to obtain all criminal history information pertaining to me in the files of the Ohio Bureau of Criminal Identification and Investigation (BCI) and the Federal Bureau of Investigation (FBI) (if requested), and to release that information to Nurses Care, Inc. By placing my fingerprint images on the WEBCHECK Scanner, I am authorizing BCI to release criminal history information about me to Nurses Care, Inc. I hereby release BCI&I and any individuals connected therewith from all liability in connection with dissemination of such criminal history information.

I agree to the release of my BCI/FBI background check results to Nurses Care, Inc.. *

Your Signature *

Your electronic signature is applied to the application, the background screening consent, and the BCI/FBI release.