GREATER ADIRONDACK HOME AIDES
PO Box 678
Glens Falls, NY 12801		 Phone:
(518) 926-7070		 Fax:
(518) 926-7074
     
In Saratoga:
call (518) 587-4379		 E-mail:
GAHA@glensfallshosp.org  		JobLine:
(518) 926-6970
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GAHA APPLICATION
Date:
First Name:*(Required)
Last Name:*
Address:*
Address:
City:*
State:*
Zip Code:*
Telephone:*
Have you ever worked under another name:*
If yes, what name:
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Position desired:
Date you can start:
Have you applied here before:
If yes, when?
Are you a NYS Certified PCA, HHA or CNA?*
If yes, which?
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Education
High School:
Location:
# of years completed:
College or Training:
Location:
# of years completed:
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Physical Record
Do you have any physical condition that may limit your ability to perform the job applied for (ie., Lifting 50-100 pounds)?*
If yes, explain:
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Legal Record
Have you ever been convicted of a misdemeanor or a felony?*
If yes, for what crime?
If yes, please explain (Convictions will not necessarily disqualify an applicant from employment):
   
Have you ever been excluded from, suspended or disbarred from or otherwise sanctioned by Medicare or Medicaid programs or any other federally funded programs?*
   
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?*
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Automobile
Do you have a reliable car available to you?*
Make:
Year:
Do you have a valid NYS driver's license?*
Do you have current auto insurance?*
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 Work History
List below your last 4 employers, beginning with the most recent. May we contact your present employer?
Employer One
Employed from:
Employed to:
Name of Employer:
Address:
Address:
City:
State:
Zip Code:
Telephone:
Position:
Salary:
Reason for leaving:
Employer Two
Employed from:
Employed to:
Name of Employer:
Address:
Address:
City:
State:
Zip Code:
Telephone:
Position:
Salary:
Reason for leaving:
 
Employer Three
Employed from:
Employed to:
Name of Employer:
Address:
Address:
City:
State:
Zip Code:
Telephone:
Position:
Salary:
Reason for leaving:
 
Employer Four
Employed from:
Employed to:
Name of Employer:
Address:
Address:
City:
State:
Zip Code:
Telephone:
Position:
Salary:
Reason for leaving:
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References
List below the names of 4 professional persons who can attest to your level of maturity, honesty and integrity. (Examples: doctor, teacher, lawyer)
Reference One
Name:
Relationship:
Address:
Address:
City:
State:
Zip Code:
Daytime Telephone:
Years Acquainted :
 
Reference Two
Name:
Relationship:
Address:
Address:
City:
State:
Zip Code:
Daytime Telephone:
Years Acquainted :
 
Reference Three
Name:
Relationship:
Address:
Address:
City:
State:
Zip Code:
Daytime Telephone:
Years Acquainted :
 
Reference Four
Name:
Relationship:
Address:
Address:
City:
State:
Zip Code:
Daytime Telephone:
Years Acquainted :
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Authorization
I authorize the investigation of all statements in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal.

If I am accepted for the training course and receive a certificate as a qualified Personal Care Aide and/or Home Health Aide, I agree that I have a moral obligation to remain in the employ of Greater Adirondack Home Aides for a minimum of 1 year thereafter.

By submitting this online application, I hereby agree to the statement, condition(s) and/or obligation(s) as outlined above.
Please enter your name:*
Please enter the date:
Comments:
 
   
 
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