AMANI HEALTH CARE SERVICES, LLC

APPLICATION FOR EMPLOYMENT

1705 Southcross Dr W Ste 105, Burnsville, MN 55306
Tel: (952) 683-1628 Fax: (952) 683-1629
Email: amanihcsllc@gmail.com  Website: amanihcs.com

Background Study

First Name is required.
Middle is required.
Last Name is required.
Please provide a valid date of birth.
Gender is required.
SSN is required.
Phone is required.
Area Code is required.
Number is required.
Race is required.
Address is required.
City is required.
State is required.
Zip is required.
Minnesota Drivers license or ID number is required.
Please provide a valid expiry date.
Aliases used is required.
Previous addresses is required.
Place of birth is required.
County is required.
Height ft is required.
in is required.
Weight is required.
Eye color is required.
Hair Color is required.
State is required.
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Where were you born is required.
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Please provide a valid email address.

I attest that the information in this application is true and accurate to the best of my knowledge and I have received a copy of privacy notice.

Full Name is required.
Date is required.

APPLICATION FOR EMPLOYMENT

Federal and State laws prohibit discrimination in employment because of sex, race, creed, religion, national origin, age, handicap, marital status, status with regard to public assistance or veteran's employment. We are an equal opportunity employer.

PERSONAL INFORMATION

Date is required.
Last Name is required.
First Name is required.
Middle is required.
Social Security Number is required.
Other surnames that I have used is required.

Present Address

Street is required.
City is required.
State is required.
Zip is required.

Permanent Address

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City is required.
State is required.
Zip is required.
Home Phone Number is required.
Alternate Phone Number is required.
How did you hear about this position is required.
Referred By is required.
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In Case of Emergency Notify

Name is required.
Phone Number is required.
Relationship to you is required.
U S Military or Naval Service is required.
Rank is required.
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EMPLOYMENT DESIRED

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Where is required.
When is required.
Please provide a valid payment desired per hour.
Please provide a valid payment agreed upon per hour.

Professional Licences, Certifications, and Registrations

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Professional Licences

Licence/Certificate/Registration Number Type State Issued Expiry Date Status

References

References

NAME ADDRESS COMPANY/POSITION PHONE

Education

Education

NAME AND LOCATION OF SCHOOL YEARS ATTENDED GRADUATED DEGREE/CERTIFICATION
HIGH SCHOOL
COLLEGE
COLLEGE
ADDITIONAL TRAINING

Employment History

Employment History

FROM / TO EMPLOYER NAME AND ADDRESS SUPERVISOR NAME MAY WE CONTACT SALARY POSITION REASON FOR LEAVING
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Full Name is required.
Date is required.

Voluntary Self-Identification Information

Amani Health Care Services, LLC is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, religion, handicapped or handicap status, marital status, source of income, class, physical characteristics, sexual orientation or political beliefs.

As an employer, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please complete this submission of this information is voluntary. This data will be kept in a confidential file separate from your Application for Employment.

Amani Employee Handbook Acknowledgement

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Employee Name is required.
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HIPAA Confidentiality and Disclosure Acknowledgement

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Printed Employee Name is required.
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Full Name of HIPAA Compliance Officer is required.
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