Employee Portal
License Renewal
800. 578. 6033

Application

Position Applying For:*
Name:*
Maiden Name/Alias:
Date of Birth:
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Address:*
Telephone:*
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Cell Phone:
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Emergency Phone #:*
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E-mail:*
Salary Required (per hour):
Current Employer & Position:
Special Training? Where? When?:
Current Salary:
Referred by:
Ever Applied Before?:*
If yes, when?:
Education
High School:
Years Attended:
Did You Graduate?:
Location:
College:
Years Attended:
Did You Graduate?:
Location:
Vocational/Adult Education:
Years Attended:
Did You Graduate?
Location:
Former Employer (most recent first)
Start Date:
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End Date:
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Currently Employed?:
Employer Name:
Employer Address:
Phone:
-
Last Salary:
Position:
Reasin For Leaving (be specific):
Former Employer (#2)
Start Date:
 / 
 / 
End Date:
 / 
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Currently Employed?:
Employer Name:
Employer Address:
Phone:
-
Last Salary:
Position:
Reason For Leaving (be specific):
Former Employer (#3)
Start Date:
 / 
 / 
End Date:
 / 
 / 
Currently Employed?:
Employer Name:
Employer Address:
Phone:
-
Last Salary:
Position:
Reason For Leaving (be specific):
Character References (other than relatives or previous employers)
Name:
Years Known:
Contact:
-
Relationship:
Name:
Years Known:
Contact:
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Relationship:
Name:
Years Known:
Contact:
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Relationship:
Other Information
Reasons you want to work for Nightingale's Nursing:*
How did you hear about Nightingale's?:*
List your personal goals:
Misc.
I certify that i have dependable transportation:*
I certify that I have access to a telephone for easy communication:*
I have a smartphone (Android or iPhone):*
I certify that I have a valid driver's license:*
I certify that I have an insured vehicle:*
Have you been convicted of a crime within the last 10 years?:*
If yes, please describe:
I understand that my job is not complete until I turn in my Care Plan/Time Sheet and agree to do so prior to receiving payment from Nightingale's:*
I understand that dependability is extremely important to home care. I will notify the office at least 3 days prior to requesting time off: *
I understand that clients have the option of refusing my services at any time and this may be of no fault of Nighingale's: *
I understand that I will be required to participate in 10 hours of in service training annually and will attend mandatory meetings: *
I certify that I have no prior mental or physical impairments that will affect or limit my work capabilities for any assignments:*
I aggree to accept responsibility for working safely:*
I agree to never accept money or tips of any kind from a client without Nightingale's permission:*
I understand that asking to borrow money from a client is grounds for immediate termination:*
I understand that entering false time on time-sheets may be fraud and is cause for termination:*
I certify that if I have ever had a workman's compensation case against an employer for personal injury that I am 100% cleared by my physician to return to work:*
Counties
Nightingale's provides services to the following counties. Please select every county in which you are willing to work:
I am willing to work withing a 50 mile radius of selected counties:
Resumé
Attach resumé:
Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of my background through SLED checks and all other information provided and release Nightingale's from all liability from any damage that may result from using such information. I also understand and agree that no representative of Nightingale's has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing, unless in writing and signed by an authorized Nightingale's representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans With Disabilities Act (ADA) and other relevant federal and state laws.

Do you agree with the authorization statement?:*

Copyright © 2015 Nightingale’s Nursing

Nightingale’s Nursing

Nightingale’s Nursing & Attendent Care Services is South Carolina’s leading at home nursing care provider. With locations in Camden, Charleston, Florence and Myrtle Beach, Nightingale’s Nursing has a service area that covers most of South Carolina. Our services include, but are not limited to, skilled nursing, respite care, in-home companionship, meal preparation, light housekeeping, errand service, personal care assistance, 24-hour care assistance, laundry & linen washing, clothing assistance, dressing & grooming guidance, rn evaluations, superior senior care, meal providers, transportation to and from doctor’s appointments, transportation for errands, medication monitoring, ongoing care, 24-hour care, respite care, homemaker care, companion care, Alzheimer’s care and disability care.

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2721 David McLeod Blvd.
Florence, SC 2950

Free: 1-800.578.6033
Tel: 843-413-6033
Fax: 843-413-6036

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