* = Required Information
APPLICATION FOR EMPLOYMENT
PERSONAL INFORMATION

Yes No
DESIRED EMPLOYMENT
Yes No
Yes No
LICENSURE/CERTIFICATION
Yes No
EDUCATION
RN CNA LPN RNA
Yes No

Yes No

Yes No
GENERAL INFORMATION
Please list any other work related information you think would be helpful to us in considering you for employment, such as foreign language, additional work experience, volunteer work, activities, accomplishments, publications, etc.

FORMER EMPLOYERS
List your last three employers, starting with the most recent one first.

Yes No

Yes No

Yes No
PERSONAL REFERENCES
Below, give the names of three persons you are not related to whom you have known for at least one year.



EXPERIENCE WITH SENIORS AND SPECIAL NEEDS POPULATIONS
Yes No
Positive Negative
Yes No
Yes No
Please answer the following questions
AUTHORIZATION
Yes No

(Should you become employed by Galaxy Home Health Care, you will be required to provide documentation proving your eligibility to work in the USA).

Yes No

(This does not apply if there was a juvenile conviction. A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has elapsed since the occurrence, and any rehabilitation you have undergone).

I authorize Galaxy Home Health Care to obtain any relevant information (including extensive local and national criminal background checks, social security verification, credit history, and motor vehicle investigations) needed to make an employment decision. I authorize Galaxy Home Health Care to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal contractual, or accreditation audits purposes. I also authorize Galaxy Home Health Care to disclose any of my performance appraisals, disciplinary records, or skills tests for the same purposes as above. I release any individual or entity providing information to Galaxy Home Health Care from all liability for any damages from the disclosure of the information.
I understand and agree that nothing contained in this employment application or in granting an interview, creates an employment contract between Galaxy Home Health Care and me for either employment or for the providing of any benefits. No promises regarding employment have been made to me. If I am offered employment, I understand it is conditional upon a successful criminal background check and that employment can be terminated “at will.” I have a right to terminate my employment at any time and that Galaxy Home Health Care also retains a similar right to terminate my employment at any time.
I understand that should I become employed by Galaxy Home Health Care, my work assignments, schedules, and work locations are subject to change according to the needs of the agency and the clients of Galaxy Home Health Care.
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 considered grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed to Galaxy Home Health Care any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release Galaxy Home Health Care from all liability for any damage that may result from utilization of such information.
Please mail this form to:
Job Application Services, HR Department
Galaxy Home Health Care, LLC
8619 Engleside Office Park, Ste. C
Alexandria, VA 22309
Alternatively you can fax the form to: 1-571-777-5068 or email: Work@galaxyhhc.com
Pursuant to Title VII of the Civil Rights Act of 1964 (42 U.S.C. Et Seq) and 45 C.F.R. part 80, section 504 of the Rehabilitation At of 1973, as amended (29 U/S/C. 794) and 45 C.F.R. Part 84, and the Age Discrimination Act of 1975 (42 U/S/C/ 6101 Et Seq) and 45 C.F.R. Part 91, Galaxy Home Health Care adheres to an equal opportunity policy for all persons seeking admission as clients or seeking employment, and for all persons employed by the agency. Galaxy Home Health Care does not discriminate because of age, race, color, religion, military status, marital status, gender preference, sex, national origin or disability.
Security code