Careers

ACT HOME HEALTH SERVICES, INC. (ACT) is an Equal Employment Opportunity Employer. ACT complies with all federal, state and local laws that prohibit discrimination. Employment actions are made without regard to race, sex (including sexual orientation, gender identity, pregnancy), color, national origin, ancestry, religious creed, handicap, age or genetic information.
Last Name*

Last
First Name*

First
Middle Initial

First
Mobile Phone*
Street Address*
City*
State*
Zip Code*
Other Phone
Other Name under which you were employed
Position Applying For*
Acceptable Salary Rate*
Social Security Number*
How did you find out about ACT*
When can you start ?*
Email*
Emergency Contact
Name

First
Relationship
Address
Telephone
Emergency Email
Are you a U.S Citizen or are you authorized to work in the U.S. ?*
Note : Verification of U.S. Citizenship or U.S. Employment Authorization will be required upon the commencement of your engagement.

Education Section

Education and Training received*

School/Training Dates Attended From Dates Attended To Graduated Subjects Studied /Degree Received

Licensure Section

Licensure/Certification Received*

State License/Certification Number Dates of Original Issue Renewal Date Expiration Date

Employment Section

Employment History*

Dates of Employed From Dates of Employed To Employer's Name/Supervisior's Name Employer's Address/Phone # Reason for Leaving Position Held

Information provided in response to these questions will not necessarily bar engagement with ACT if the answers to questions 1,2 or 4 are “YES”.Please give full details on a separate sheet.

Questions
1. Has your clinical license to practice in any jurisdiction ever been limited, suspended or revoked?*
2. Have your clinical privileges ever been suspended, diminished, revoked or not renewed?*
3. Do you have the ability to perform all essential job functions?*
4. If engaged by ACT, will you consent to a physical examination?*
5. Where you in the United States Armed Forces?*
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School/Training	Dates Attended From	Dates Attended To	Graduated	Subjects Studied /Degree Received

State	License/Certification Number	Dates of Original Issue	Renewal Date	Expiration Date

Dates of Employed From	Dates of Employed To	Employer's Name/Supervisior's Name	Employer's Address/Phone #	Reason for Leaving	Position Held