List the name addresses, numbers of individuals you have worked with (preferably) in other Home Care Agencies, LTC ,ALC Any health care settings. If you need a phone book please ask
EMPLOYMENT HISTORY: START WITH THE MOST RECENT EMPLOYER
Family Care Registry Checks (FCSR) must be registered
Employee Disqualification List (EDL)
Two (2) credible Reference Checks.
STATEMENT OF UNDERSTANDING:
This Agency does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, age, marital status, veteran status, or handicap. No question on this application is intended to secure information to be used for such discrimination.
I authorize investigation of all statements contained in this application if I am considered for employment. I also authorize previous employers named, or any other person to whom this agency may refer, to give any and all information regarding my employment or scholastic standing together with any other pertinent information
I understand the misrepresentation or omission of facts requested on this application or other employment documents, unsatisfactory work references, or failure to pass the prescribed physical examination (if required for my position) will be sufficient cause for dismissal from the agency's service. If it is discovered after I am hired.
To help ensure a safe and healthful working practices, the agency reserves the right to ask employees to provide body substance samples (such as urine/blood) to determine the illicit or illegal use of drugs and alcohol.
Testing Procedures can be initiated for post - accident/incident situations. Situations where in the judgment of the agency that the employee demonstrates impairment from the use of drugs or alcohol, and situations concerning the suspected theft of controlled substances owned by the client. Refusal to submit to drug/alcohol testing will result in termination of employment
Since the agency operates 24 hours a day and may have priority clients, I understand it may be necessary for me to be assigned clients, work, shifts or days which do not coincide with my client/work preferences listed on this employment application. I also understand that management has the sole right to assign client/job duties, outside of my normal client/duties, In order to meet operational needs or provide care to the clients
I also understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this agency is of an "At Will" nature, Which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this "At Will" employment re lationship may not be changed by any written document or conduct unless such change is specifically acknowledged in writing by the chief operating officer of the agency.
a. The Employee fulfills the following minumun Requirements for hire as In-Home service Aide.
b. Employee is 18 years of age: Yes No
c. Employee is able to Read, Write and Follow instructions: Yes No
Employee meets one of the following experience Qualifications:
NOTE: For the following experience categories it is necessary to provide a detailed explanation as to why the person is Qualified in the additional information section
Position Applied for with us: (please circle) CNA, Personal/Home Care Aide, RN, LPN, Office Personnel
I Certify that I have read, understand and intend to comply with the Formal Applican t Agreement Form and associated Professional Conduct Expectations and that the facts contained in this application are true and accurate. I understand that any misrepresentation or omission of facts is cause for dismissal. I authorize the employer to inves tigate any and all statements contained herein and request the persons, firm/s, and/or corporation named above to answer any and all questions relating to this application. I release all parties from liabi lity, including but not limited to, the employer an d any person, or firm.
BEFORE SUBMITTING THIS APPLICATION, YOU MUST AGREE TO THE ABOVE AND FOLLOWING TERMS AND CONDITIONS.
I confirm that the information provided in this application is complete and accurate, to the best of my knowledge. I und erstand that providing incomplete or inaccurate information may result in disqualification from possible employment with On Call Care Services, LLC, and may be a violation of state law(s) that could result in civil penalties. On Call Care Services, LLC is authorized to obtain information from my current and previous employers, and to release information in support of my application for work (application, references, background sea rch results, etc.) to client institutions and to appropriate governmental or l icensing bodies. On Call Care Services, LLC may also share applicant information with its affiliates connected to seeking employment. I understand that On Call Care Services, LLC, certain states and/or client institutions may re quire criminal background ch ecks and Reference checks By typing my name on this application I gave consent to such checks.