TNY NHP 4.0- Part 1

APPLICATION FOR EMPLOYMENT
FIRST NAME*
MIDDLE INITIAL
LAST NAME*
ADDRESS*
APT #
CITY*
STATE*
ZIP CODE*
PHONE*
EMAIL*
example@example.com
POSITION APPLYING FOR*
PLEASE NOTE THAT WHILE WE WELCOME NEW GRAD CNAs, WE CANNOT GIVE YOU WORK UNTIL YOU RECIEVE YOUR CERTIFICATE FROM THE STATE OF NY AND APPEAR IN THE PROMETRIC DATABASE. PLEASE NOTIFY YOUR RECRUITER IF YOU ARE APPLYING BEFORE TAKING YOUR EXAM.
Please note Towne Nursing is not a licensed homecare agency. This means we cannot keep your HHA Certificate Active. You must work at least 8hrs in two years with a licensed homecare agency to keep your certificate active.
LICENSE NUMBER
EXPIRATION DATE

MonthDayYear
Date
Upload your License/Certificate here (if you don't have it now, you can submit it later)

Cancelof
EMERGENCY CONTACT
NAME (FIRST & LAST)
RELATIONSHIP
PHONE
EDUCATION
SCHOOL
DEGREE EARNED
YEAR
EMPLOYMENT HISTORY
EMPLOYER NAME
SUPERVISOR NAME
LOCATION OF EMPLOYMENT
POSITION HELD
PHONE
DATES OF EMPLOYMENT
PROFESSIONAL REFERENCES
NAME
TITLE
EMPLOYER
PHONE
MY SIGNATURE VERIFIES THAT INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND COMPLETE. I UNDERSTAND THE AGENCY IS AN EQUAL OPPORTUNITY EMPLOYER. I UNDERSTAND THAT FALSIFICATION, INCLUDING WITHHOLDING OF INFORMATION, ON THIS APPLICATION IS GROUNDS FOR IMMEDIATE DISMISSAL IF I AM SELECTED FOR A POSITION. I FURTHER UNDERSTAND THAT IF I AM HIRED, I CAN BE TERMINATED, WITH OR WITHOUT CAUSE AND WITH OR WITliOUT NOTICE. I UNDERSTAND THE AGENCY HAS THE RIGHT TO RUN A CRIMINAL BACKGROUND CHECK AND MAY PASS ON THE RESULTS UPON REQUEST. I UNDERSTAND THAT THE PHYSICAL INFORMATION THAT THE EMPLOYEE MUST PROVIDE TO OUR AGENCY MAY BE RELEASED TO ANY FACILITY UPON THEIR REQUEST. I UNDERSTAND THAT ALL REFERENCES LISTED ABOVE MAY BE CONTACTED IN ADDITION TO PAST EMPLOYERS AND EDUCATIONAL INSTITUTIONS .
BY SIGNING THIS, I VERIFY THAT I HAVE READ THE ABOVE HAD AN OPPORTUNITY TO CLARIFY INFORMATION ABOUT ITEMS DO NOT UNDERSTAND AND AGREE WITH THE ABOVE PARAMETERS
Signature*

Clear
Date*

MonthDayYear
Date
AVAILABILITY
FULL TIMEPART TIMEPER DIEM
SHIFT
MORNINGEVENINGNIGHT
SCHEDULING PREFERENCES
WHICH AREA(S) DO YOU PREFER TO WORK IN?*

BRONXBROOKLYNSTATEN ISLANDQUEENSLONG ISLANDWESTCHESTERMANHATTANROCKLANDUPSTATEOTHER
MODE OF TRANSPORTATION

DRIVES OWN CARPUBLIC TRANSPORTATION
SKILLS
HOW MANY MONTHS OF EXPERIENCE DO YOU HAVE?*

0-3 MONTHS3-6 MONTHS6 MONTHS- 1 YEAR1 YEAR- 5 YEARS5 YEARS- 10 YEARS10+ YEARS
DO YOU SPEAK ANY ADDITIONAL LANGUAGES?

SPANISHRUSSIANTAGALOGMANDARIN/CHINESE
DO YOU HAVE EXPERIENCE WITH AN EMR PROGRAM?

YESNO
IF YES, WHICH EMR PROGRAM DO YOU HAVE EXPERIENCE WITH?

SIGMA CAREPOINT CLICK CARERELIABLE RHSVISUALIDXEPIC
HOW DID YOU HEAR ABOUT US?

Towne WebsiteGoogleIndeedFacebook/InstagramFriend/FamilyFacility
Referred By A Friend

First NameLast Name
Referred By A Facility
POLICIES AND PROCEDURES

PLEASE FAMILIARIZE YOURSELF WITH THE FOLLOWING GUIDELINES TO MAKE YOUR TOWNE NURSING EXPERIENCE SMOOTH AND SATISFACTORY.
PLEASE READ EACH BULLET POINT CAREFULLY AND CHECK OFF ONCE READ*

1. PLACEMENT/SCHEDULING. Quick and easy communication is the key to getting work. Please make sure we always have a current working number where you can be reached, and listen to your messages regularly. Please contact your coordinator if your availability changes. The amount of work you get from us is directly related to how often we hear from you and how easily we are able to contact you.2. CANCELATIONS. If you have a true emergency and you must cancel, call us as soon as possible. Call your coordinator and state the reason for canceling. If a shift is canceled due to a medical emergency involving yourself or a family member, be prepared to provide documentation when returning to work. Not showing up for a scheduled shift will not be tolerated, it is in your best interest to NEVER “No Call” or “No Show “to a scheduled shift, as this may result in immediate termination. Remember, there is always a coordinator available to take your calls, day and night. Therefore, place a call to us as soon as something comes up that may prevent you from showing up to your shift in a responsible manner. Please give us as much advance notice as possible.3. CONFIRMATIONS. After your calendar/shifts are confirmed at your facility you cannot change your schedule. Please only submit availability that you can be scheduled for.4. SIGN-IN SYSTEM. Payroll is done on a weekly basis. Typically payday is on Friday. Please make sure your direct deposit information is correct. You will use the facilities system to punch in and out for every shift.In the event that there is a need for you to stay for overtime; prior authorization is required from the facility, and make sure the nurse who signs for you is aware of the time change.5. DRESS CODES. Please always report to work in a professional manner, in uniform, wearing your Towne Nursing Staff ID badge or badge provided by the facility.
Signature*

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Date*

MonthDayYear
Date
EMPLOYEE AGREEMENT

Agreement made on TODAYS DATE by and between Towne Nursing Staff Inc. (hereinafter referred to as “Agency”), and YOU, (hereinafter referred to as “Employee” ). This does not constitute the entire agreement between the parties. In consideration of the mutual promises and obligations between the parties, some of which are contained herein, the parties hereto agree as follows:
PLEASE READ EACH BULLET POINT CAREFULLY AND CHECK OFF ONCE READ*

1. Nothing shall prevent the employee from entering into any agreement with any other nursing employment agency or facility. However, the employee agrees that once he/she has been introduced to any facility through Towne Nursing Staff, Inc, that he/she may not work at the same facility through any other agency; and not independently.2. Upon introduction to a facility, the agency will set up an orientation. This orientation is training for the possible shift availability at that particular institution. Employee will be paid for the orientation day\s only upon approval for work at that facility.3. Towne Nursing Staff presents its employees with different employment opportunities and shift availability. At the time of these conversations, employee can decide whether or not he\she is available to do the assignment\orientation. Once the individual accepts the schedule, the employee is expected to show up to the assignment. In unforeseen circumstances requiring cancellation, employee agrees to notify Agency at least 24 hours in advance of the scheduled shift. In the case of an emergency, employee must call at the earliest possibility to inform agency that he\she will not be able to report to work. Towne Nursing Staff is open 24 hours a day, seven days a week in case of these emergencies. Not showing up to work without notifying the agency is not acceptable.4. Employee is responsible for following the time record maintenance protocol. This may include signing in and out on an agency sign in sheet, and/or clocking in and out on a timecard.5. The following holidays will be paid at overtime rates: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving and Christmas Day. *Please be advised that night shift on overtime pay for holidays varies between facilities.6. Employee will get assignments based on the employee’s availability and the agency needs. In the event that the institution requests the employee to work over forty hours in one pay period, employee must get authorization from the Agency.7. By signing this agreement you are acknowledging that all facilities contracted with Towne Nursing Staff Inc require agency staff to work alternating weekends.
Signature*

Clear
Date*

MonthDayYear
Date
UPON COMPLETION OF THIS APPLICATION A RECRUITER WILL BE IN TOUCH WITH YOU. BELOW IS A COPY OF THE CREDENTIALS WE WILL BE REQUIRING FOR YOU TO REVIEW (THIS LIST IS NOT ALL INCLUSIVE)

WE THANK YOU FOR YOUR INTEREST IN TOWNE NURSING NEW YORK AND LOOK FORWARD TO WORKING WITH YOU!
Should be Empty:

APPLICATION FOR EMPLOYMENT

EDUCATION

EMPLOYMENT HISTORY

PROFESSIONAL REFERENCES

AVAILABILITY

SHIFT

SCHEDULING PREFERENCES

SKILLS

POLICIES AND PROCEDURES

EMPLOYEE AGREEMENT