Asian Community Care Management/ Mega Stone Management Inc. EMPLOYMENT APPLICATION FORM

Asian Community Care Management/ Mega Stone Management Inc. EMPLOYMENT APPLICATION FORM
This application must be completed and all questions regarding your training and workexperience answered. All information on this application is confidential, MEGA STONE MANAGEMENT, INC.will not contact your present employer without your consent.
Name*

First NameMiddle NameLast Name
FemaleMale
Street Address 1*
City
State
Zip Code
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
HomePhone
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email 1*
example@example.com
Email 2
example@example.com
Emergency Confact Name*
Relationship*
Emergency Contact Phone*
Format: (000) 000-0000.
Administrative positionClinical PositionCare Management AssociateOther
Pre-Interview Questionnaire
Can you describe an example of a situation where you provided exceptional customer service/patient care?
Can you describe a situation in which you had to serve a difficult customer/patient? Which approaches did you use to deal with the situation?
Why do you think you will be a good fit for this position?
Microsoft WordMicrosoft ExcelPDFMicrosoft PowerpointOther
When are you available to work?

MonthDayYear
Date
BronxQueensBrooklynManhanttanLong IslandStaten Island
Skilled Nurse/UAS Nurse Interview Questionnaire
YesNo
YesNo
If Yes, Please provide your UAS account username:
YesNo
How many cases per week are you looking to have?
Check at least 2 areas that interest you the most (1 as your first choice, 2 as your second)
Manhattan
Queens
Bronx
Brooklyn
Staten Island
Long Island
YesNo
Self SchedulingDelegated Scheduling
What days are you available to work? (Please provide a specific time)
Monday   Type a label
Tuesday   Type a label
Wednesday   Type a label
Thursday   Type a label
Friday   Type a label
YesNo
If Yes, which days are you available? (Please provide a specific time)
Saturday Type a label
Sunday Type a label
YesNo
Primary Language Spoken
LowModerateFluent
Secondary Language Spoken
LowModerateFluent
How many hours a week are you available for work
Minimum Salgry Requirement
Date Available

MonthDayYear
Date
Employment Reference
Employer 1's Name
Address
Phone
Format: (000) 000-0000.
Email
example@example.com
From Mo/Yr:
To Mo/Yr:
Job Title
Supervisor's Name
Salary (Optional)
Reason for leaving
Type option 1
Employer 2's Name
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
From Mo/Yr:
To Mo/Yr:
Job Title
Supervisor's Name
Salary (Optional):
Reason for leaving
Professional Reference:
Type option 1
Reference Name
Email
example@example.com
Phone
Format: (000) 000-0000.
Reference Name
Emoil
Phone
Format: (000) 000-0000.
YesNo
If Yes, by Whom
YesNo
Professional Licenses
Professional Licenses
Profession
Lic.No
Exp. Date

MonthDayYear
Date
Professional Licenses
Profession
Lic.No
Exp. Date

MonthDayYear
Date
School/Training Program
I certify that the facts contained in this application are true and complete to the best of my knowledge andunderstand, that, if employed; falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I Authorize complete investigation of all statements contained herein and hereby give my full permissionfor the Agency to contact and fully discuss my background and history with all persons and entities listedabove to give the Agency any and all information concerning my previous employment and any infor-mation they may have, and release all former employees and others listed above from all liability for anydamage that result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of thedate of payment of my wages and salary, be terminated at any time for any lawful reason, without priornotice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Anyapplicant wishing to be considered for employment beyond this time period shall inquire as to whether ornot applications are being accepted at that time
Signature
Date

MonthDayYear
Date
Should be Empty:

Asian Community Care Management/ Mega Stone Management Inc. EMPLOYMENT APPLICATION FORM

Pre-Interview Questionnaire

Skilled Nurse/UAS Nurse Interview Questionnaire

Employment Reference

Professional Reference:

Professional Licenses