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Agency Application

By submitting an application, I acknowledge I have read and understand the job description

Name*
First Last
Phone*
Email
Application Profile
ALL FIELDS must be completed to be considered for employment.
I am a*
- HHA
- FL Licensed CNA
If HHA, how many hours?*
Do you have Professional Liability Insurance?*
- Yes
- No
What work are you looking for?*
- Hourly
- Days
- Shifts
- Evenings/Overnights
- Medicare Bath Visits
- Weekends
What days can you work?*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
In what cities can you work?*
For example: list individual cities or a range, such as Boca Raton to West Palm Beach
Do you drive? (Must have valid drivers license)*
- Yes
- No
Do you have your own car? (Must have valid auto insurance)*
- Yes
- No
Will you work with pets?*
- Yes
- No
Will you work with smokers?*
- Yes
- No
Have you ever worked for FirstLantic?*
- Yes
- No
When did you work for FirstLantic?*
Why did you stop working for FirstLantic?*
Do you have the following documents?
HHA Certificate with curriculum (40 or 75+ hours) and/or CNA License?*
- Yes
- No
Social Security Card?*
- Yes
- No
Valid Drivers License or Photo ID?*
- Yes
- No
Auto Insurance?*
- Yes
- No
Professional Liability Insurance?*
- Yes
- No
Physical (within 6 months) from MD, DO, ARNP, or PA?*
- Yes
- No
PPD (within 6 months) or Chest X-ray (within 2 years) from MO, DO, ARNP, or PA?*
- Yes
- No
Proof of eligibility to work in the US (if applicable)?*
- Yes
- No
CPR Card (Current/Active and NO online courses)*
- Yes
- No
CEUs
OSHA/TB/BBP Certificate?*
- Yes
- No
Assisting with Self Administration of Medication Certificate?*
- Yes
- No
Domestic Violence Certificate?*
- Yes
- No
Alzheimer's / Communicating with Cognitively Impaired Certificate?*
- Yes
- No
AIDS / HIV Certificate?*
- Yes
- No

Save and Continue Later

Application Details
Date Available*
Date Format: MM slash DD slash YYYY
Primary Language*
Secondary Language*
Drivers License #*
Drivers License State of Issuance and Expiration Date*
Were you referred to our company?*
- Yes
- No
If referred, by whom?*
Are you a citizen of the US?*
- Yes
- No
If no, are you authorized to work in the US?*
Have you ever been convicted of a felony?*
- Yes
- No
If convicted of felony, please explain?*
Have you ever served in the military?*
- Yes
- No
If military service, which branch and dates of service?*
Rank at discharge?*
If other than honorable discharge, please explain*

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Education
High School*
Dates attended high school*
Did you graduate high school?*
- Yes
- No
High School Location*
City State / Province / Region Country
College*
Dates attended college*
Did you graduate college?*
- Yes
- No
If a college graduate, what is your degree and field of study?*
College Location*
City State / Province / Region Country
Other Education
- Yes
- No
Other Education Details
Please provide institution(s), dates attended, location, and degrees obtained.
Licenses and Certifications
Provide a detailed list, with license/certificate #, state, school, and expiration date.
Upload a copy of all licenses and certificates held.

Save and Continue Later

Employment History
Previous Employer 1
Address - Previous Employer 1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone # - Previous Employer 1
Supervisor - Previous Employer 1
Job Title - Previous Employer 1
Responsibilities - Previous Employer 1
Dates or Employment - Previous Employer 1
May we contact your supervisor at previous employer 1?
- Yes
- No
Previous Employer 2
Address - Previous Employer 2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone # - Previous Employer 2
Supervisor - Previous Employer 2
Job Title - Previous Employer 2
Responsibilities - Previous Employer 2
Dates or Employment - Previous Employer 2
May we contact your supervisor at previous employer 2?
- Yes
- No
Previous Employer 3
Address - Previous Employer 3
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone # - Previous Employer 3
Supervisor - Previous Employer 3
Job Title - Previous Employer 3
Responsibilities - Previous Employer 3
Dates or Employment - Previous Employer 3
May we contact your supervisor at previous employer 3?
- Yes
- No

Save and Continue Later

References
Do you consent to authorizing FirstLantic Healthcare to contact the below references to make inquiries about past job performance, your character, and ability to perform the required job responsibilities?*
- Yes
- No
Name - Reference #1*
Reference Type - Reference #1*
- Personal Reference
- Professional Reference
Phone # - Reference #1*
Address - Reference #1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name - Reference #2*
Reference Type - Reference #2*
- Personal Reference
- Professional Reference
Phone # - Reference #2*
Address - Reference #2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name - Reference #3*
Reference Type - Reference #3*
- Personal Reference
- Professional Reference
Phone # - Reference #3*
Address - Reference #3
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Disclaimer
Certification*
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand false or misleading information in my application or interview may result in my release.
- Yes, I agree
- No, I do not agree
Digital Signature*
Please type out your full name to electronically certify your application.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Name*
First Last
Phone*
Email
Application Profile
ALL FIELDS must be completed to be considered for employment.
I am a*
- HHA
- FL Licensed CNA
If HHA, how many hours?*
Do you have Professional Liability Insurance?*
- Yes
- No
What work are you looking for?*
- Hourly
- Days
- Shifts
- Evenings/Overnights
- Medicare Bath Visits
- Weekends
What days can you work?*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
In what cities can you work?*
For example: list individual cities or a range, such as Boca Raton to West Palm Beach
Do you drive? (Must have valid drivers license)*
- Yes
- No
Do you have your own car? (Must have valid auto insurance)*
- Yes
- No
Will you work with pets?*
- Yes
- No
Will you work with smokers?*
- Yes
- No
Have you ever worked for FirstLantic?*
- Yes
- No
When did you work for FirstLantic?*
Why did you stop working for FirstLantic?*
Do you have the following documents?
HHA Certificate with curriculum (40 or 75+ hours) and/or CNA License?*
- Yes
- No
Social Security Card?*
- Yes
- No
Valid Drivers License or Photo ID?*
- Yes
- No
Auto Insurance?*
- Yes
- No
Professional Liability Insurance?*
- Yes
- No
Physical (within 6 months) from MD, DO, ARNP, or PA?*
- Yes
- No
PPD (within 6 months) or Chest X-ray (within 2 years) from MO, DO, ARNP, or PA?*
- Yes
- No
Proof of eligibility to work in the US (if applicable)?*
- Yes
- No
CPR Card (Current/Active and NO online courses)*
- Yes
- No
CEUs
OSHA/TB/BBP Certificate?*
- Yes
- No
Assisting with Self Administration of Medication Certificate?*
- Yes
- No
Domestic Violence Certificate?*
- Yes
- No
Alzheimer's / Communicating with Cognitively Impaired Certificate?*
- Yes
- No
AIDS / HIV Certificate?*
- Yes
- No

Save and Continue Later

Application Details
Date Available*
Date Format: MM slash DD slash YYYY
Primary Language*
Secondary Language*
Drivers License #*
Drivers License State of Issuance and Expiration Date*
Were you referred to our company?*
- Yes
- No
If referred, by whom?*
Are you a citizen of the US?*
- Yes
- No
If no, are you authorized to work in the US?*
Have you ever been convicted of a felony?*
- Yes
- No
If convicted of felony, please explain?*
Have you ever served in the military?*
- Yes
- No
If military service, which branch and dates of service?*
Rank at discharge?*
If other than honorable discharge, please explain*

Save and Continue Later

Education
High School*
Dates attended high school*
Did you graduate high school?*
- Yes
- No
High School Location*
City State / Province / Region Country
College*
Dates attended college*
Did you graduate college?*
- Yes
- No
If a college graduate, what is your degree and field of study?*
College Location*
City State / Province / Region Country
Other Education
- Yes
- No
Other Education Details
Please provide institution(s), dates attended, location, and degrees obtained.
Licenses and Certifications
Provide a detailed list, with license/certificate #, state, school, and expiration date.
Upload a copy of all licenses and certificates held.

Save and Continue Later

Employment History
Previous Employer 1
Address - Previous Employer 1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone # - Previous Employer 1
Supervisor - Previous Employer 1
Job Title - Previous Employer 1
Responsibilities - Previous Employer 1
Dates or Employment - Previous Employer 1
May we contact your supervisor at previous employer 1?
- Yes
- No
Previous Employer 2
Address - Previous Employer 2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone # - Previous Employer 2
Supervisor - Previous Employer 2
Job Title - Previous Employer 2
Responsibilities - Previous Employer 2
Dates or Employment - Previous Employer 2
May we contact your supervisor at previous employer 2?
- Yes
- No
Previous Employer 3
Address - Previous Employer 3
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone # - Previous Employer 3
Supervisor - Previous Employer 3
Job Title - Previous Employer 3
Responsibilities - Previous Employer 3
Dates or Employment - Previous Employer 3
May we contact your supervisor at previous employer 3?
- Yes
- No

Save and Continue Later

References
Do you consent to authorizing FirstLantic Healthcare to contact the below references to make inquiries about past job performance, your character, and ability to perform the required job responsibilities?*
- Yes
- No
Name - Reference #1*
Reference Type - Reference #1*
- Personal Reference
- Professional Reference
Phone # - Reference #1*
Address - Reference #1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name - Reference #2*
Reference Type - Reference #2*
- Personal Reference
- Professional Reference
Phone # - Reference #2*
Address - Reference #2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name - Reference #3*
Reference Type - Reference #3*
- Personal Reference
- Professional Reference
Phone # - Reference #3*
Address - Reference #3
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Disclaimer
Certification*
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand false or misleading information in my application or interview may result in my release.
- Yes, I agree
- No, I do not agree
Digital Signature*
Please type out your full name to electronically certify your application.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later

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24 hours a day, 7 days a week:

Locations

Palm Beach County 2605 W. Atlantic Ave. Bldg. A, #202 Delray Beach, FL 33445

Broward County 3201 W. Commercial Blvd. #220 Ft. Lauderdale, FL 33309

Click here for a complete list of cities we serve

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LICENSE NUMBERS

HHA 20157096 • 30211112 • 30211184

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