Symmetrix Home HealthCare Inc.

Contact Information

Symmetrix Home HealthCare, Inc.
411 E Business Center Drive Suite 106
Mount Prospect, IL 60056

Phone: (847) 430-6771
Fax: (847) 430-6770
info@symmetrixhhc.com

Business Hours:
Monday - Friday
9 am - 5 pm
24/7 Hotline (847) 430-6771

Application Form (part 1 of 4)

* Required Information

Application For Employment

Date: February 07, 2012

* First Name	* Last Name	Middle Initial
* Street Address	Unit Apartment #	* Zip Code
* City	* State

* Telephone #		Mobile/Beeper/Other Phone #
Email

* Position(s) applied for

Referral Source (Please check the appropriate category and name the source.)

Walk In		School
Employee		Job Fair
Advertisement		Staffing Agency
Company's Website		Government Employment Agency
Other Internet		Other

If necessary, best time to call you at home is
May we contact you at work?	Yes No
If yes, work number and best time to call

If you are under 18 and it is required, can you furnish a work permit?	Yes No
If no, please explain

Have you submitted an application here before? Yes No

If yes, give date(s) and position(s)

Have you ever been employed here before? Yes No

If yes, give date(s)

From To

Are you legally eligible for employment in this country? Yes No

Date available for work

* What is your desired salary range or hourly rate of pay?

$ Per

Type of Employment Desired	Full Time Part-Time Temporary

Type of work schedule interested in (Check all that apply.)	Days (1st Shift) Evenings (2nd Shift) Nights (3rd Shift) Pool Weekends Split Shift Rotating Shift Overtime

Will you relocate if job requires it?	Yes No

Will you travel if job requires it?	Yes No

If they have been explained to you, are you able to meet the attendance requirements of the positions?	N/A Yes No

Will you work overtime if required?	Yes No
If no, please explain
Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary, These issues may be addressed at a later stage to the extent permitted by law.
Yes No Need more information about the job's "essential functions" to respond

Driver's license number required if driving may be required in the job for which you are applying

Have you ever been bonded? Answering "yes" to the following questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.	Yes No

Have you ever pleaded "guilty" of "no contest" to, or been convicted of a crime?	Yes No
If yes, please provide date(s) and details

Have you entered into an agreement with any former employer or other party (such as a non-competition agreement) that might, in any way, restrict your ability to work for our company?	Yes No
If yes, please explain