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Helping Others Really Pays

Join Our Team

We encourage compassionate, experienced, and new nurses and caregivers to join our team to make a positive difference in the lives of individuals with disabilities by providing personalized home healthcare support and creating a community that values professional caregiving.

Nurse & Caregiver Application Form

Name *

First

Last

Former/Maiden

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Upload Current Resume

Click or drag a file to this area to upload.

How did you find out about this position? *

Current Employee
Family
Friend
Career Fair
Newspaper Ad
Radio/TV Ad
Search Engine
Social Media
Craigslist
Other

If other

Which position are you applying for? *

Were you referred by an existing employee? *

Who referred you? *

Days you are available to work? *

Times you are available to work? *

You will be required to work two weekends per month or holidays as needed *

When can you start? *

Highest Level of Education *

Skills *

Previous Employment & Professional References

Company Name *

Phone *

Dates of Employment *

Salary/Hourly Wage *

Job Title *

Responsibilities *

Reasons for Leaving *

May we contact this employer for a reference check? *

Professional Work Reference (please list 2)

Name *

First

Last

Company Name *

Phone *

Email *

Name *

First

Last

Company Name *

Phone *

Email *

Do you have a valid drivers license? *

Do you have reliable transportation? *

Are you a veteran? *

Have you ever been convicted of a misdemeanor or a felony? *

Rate of pay desired? *

Criminal Background Check Release

Release of Information *

Clear Signature

I allow my perspective employer Community Home Health Care to verify information given to him or her on my application for employment and do hereby release Community Home Health Care, State Police, and their assigns or successors from any liability of claims and authorize the State Police to release to Community Home Health Care my conviction criminal history information.

Your Driver's License Number *

Issuing State *

Date of Birth *

Sex *

Verification, I attest, under penalty of perjury, that I am (check one of the following) *

A citizen of the United States
A noncitizen national of the United States
A lawful permanent resident
An alien authorized to work

I am aware that federal law provides for imprisonment and/or fines for false statements of use of false documents in connection with the completion of this form.

Alien Registration Number (if applicable)

Sign & Submit *

Clear Signature

I confirm that the facts set forth in my application and submitted resume are true and complete to the best of my knowledge, that I shall ensure that such facts remain true and accurate for the duration of my employment with Community Home Health Care.

Date / Time

Date

Time

Equal Opportunity Employer

Community Home Health Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.

This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Community Home Health Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.

Contact Us

 4640 West Jefferson Blvd Fort Wayne IN,
46804
 
 (260) 441-8302
 
 Mon-Fri 8:00am-5:00pm
 
 kaiaz@communityhomehealthcare.com

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Our Service Areas

Indiana Northeast: Adams, Allen, Dekalb, Huntington, Nobel, Wells & Whitley

Indiana Northwest: Lake, Porter, LaPorte, St. Joseph, Starke, Pulaski, Jasper & Newton

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Contact Us
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