Application Form

* = Required Information

Employment Application Form

Last Name *

First Name *

M.I. *

Date *

Present Address *

City *

State *

Zip *

Permanent Address *

City *

State *

Zip *

Home Phone *

Cell *

Email *

Nursing License Number *

Date Available

Social Security Number

Desired Salary

Position(s) applying for:

Part time

Full time

Shift Preferred

Emergency Contact:

Address

Phone

Are you 18 years of age or older?

Yes

Are you authorized to work in the U.S.?

Yes

Are you a former Employee?

Yes

When?

Do you have any aliases?

Yes

Please list them:

Can you perform the job functions, tasks, or duties, with or without reasonable accommodation, of the position(s) applied for?

Yes

Please explain.

How did you hear about us?

EDUCATION

High School

Address

From

Did you graduate?

Yes

Degree

College

Address

From

Did you graduate?

Yes

Degree

Other

Address

From

Did you graduate?

Yes

Degree

Professional Licenses/Certification:

Type

State issued

Date issued

Expires

Yes

PROFESSIONAL REFERENCES

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

Full Name

Classification/position

Company

Phone

Address

Relationship

Full Name

Classification/position

Company

Phone

Address

Relationship

Full Name

Classification/position

Company

Phone

Address

Relationship

EMPLOYMENT HISTORY: START WITH THE MOST RECENT EMPLOYER

Employer

Phone

Address

City

State

Zip

Job Title

Starting Salary $

Ending Salary $

Briefly describe duties

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Employer

Phone

Address

City

State

Zip

Job Title

Starting Salary $

Ending Salary $

Briefly describe duties

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Employer

Phone

Address

City

State

Zip

Job Title

Starting Salary $

Ending Salary $

Briefly describe duties

Responsibilities

From

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

Name

Date

SIGNATURE

Date

Employment Application

NAME

BACKGROUND CHECK:

Disclose if you have ever pled guilty to, been convicted for, been released without imposition of sentence, and pleas of nolo contendere, or received pretrial diversion for any crime, excluding minor traffic tickets? (Please Include expunged conviction)

Yes

Describe all of these actions, including the nature of the criminal offense(s), the location(s), the dates, and their disposition. Conviction of a crime is not an automatic bar for employment. Falsification of information will result in rejection of application or termination of employment

Disclose if you have ever been placed on the Employee Disqualification List (EDL)?

Yes

Disclose if you have ever been placed on the Employee Disqualification List (EDL)?

Yes

I hereby give consent to this agency to conduct a thorough investigation of my pre-employment criminal record checks, and closed records checks, and background & highway patrol checks as deemed necessary by law for this employment purposes.Potential Employee must meet the basic requirement for hire which includes, but not limited to these checks:

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.

NAME

Date

SIGNATURE

Date

EMPLOYEE MINIMUM QUALIFICATIONS FOR HIRE
Fill your name in blank below

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

1. Has at least 6 months paid experience as:

Agency Homemaker

Nurse Aide

Maid

2. Has at least 1 years’ experience (Paid or Unpaid) :

Caring for Children

Elderly

Infirm

3. Has Successfully completed Training as:

Certified Nurse Aide

LPN

4.List two (2) jobs that lasted six (6) or more months:
A:
B:

Additional Information:

Name

Date

Signature

Date

Employment Reference Check

Name of Employee:

SSN

Former Employer's Name:

Position Held:

Employment Dates:

From:

To:

Special Training Received?

Attendance Record:

Major reasons for missed work:

Are there any Disciplinary Issues?

Yes

Please explain:

Does employee need constant supervision?

Why did employee leave employment?

Would you re-hire this employee?

Position Applied for with us: (please circle) CNA, Personal/Home Care Aide, RN, LPN, Office Personnel

Name of Reference Giver

Title

Phone

Fax

Check Conducted by

Title

Information obtained via

Certified Nurse Aide

LPN

Signature

Name

Date

Employee Signature

Date

Addmore

Name of Employee:

SSN

Former Employer's Name:

Position Held:

Employment Dates:

From:

To:

Special Training Received?

Attendance Record:

Major reasons for missed work:

Are there any Disciplinary Issues?

Yes

Please explain:

Does employee need constant supervision?

Why did employee leave employment?

Would you re-hire this employee?

Position Applied for with us: (please circle) CNA, Personal/Home Care Aide, RN, LPN, Office Personnel

Name of Reference Giver

Title

Phone

Fax

Check Conducted by

Title

Information obtained via

Certified Nurse Aide

LPN

Signature

Name

Date

Employee Signature

Date

Release of Information:

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.

PLEASE NOTE:

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.