* = Required Information
Date
*
Referred By
*
Name
*
Disclose all aliases and social security numbers used
*
DOB
*
SSN
*
Address
*
City
*
State
Zip Code
Home Phone
*
Cell Phone
*
Email Address
*
State I.D Number
Emergency Contact
*
Phone Number
Position Applying For
Hours Per Week
Please check the days you are available to work
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Do you prefer to work with males or females?
Males
Females
Both
Please indicate the following assistance you are willing and able to perform for clients.
Dressing
Showering
Toilet Assistance
Transferring
Meal Preparation
Feeding
Running Errands/Shopping
Laundry/Cleaning
Bill Assistance/Correspondence
Do you own your own transportation?
Yes
No
Current Driver’s License?
Yes
No
Are you a legal citizen of the U.S.?
Yes
No
BACKGROUND:
A background screening with the Family Care Safety Registry must be performed prior to employment.
Do you consent to a closed records check?
*
Yes
No
Do you consent to a pre-employment criminal record check?
*
Yes
No
Are you listed on the Employment Disqualification List?
Yes
No
Are you registered with the Family Care Safety Registry?
*
Yes
No
Have you been charged with an offense other than a minor traffic violation?
Yes
No
Please list any and all convictions.
(Failure to disclose this information can/will result in termination)
State
Offense
Date
Any pending charges?
Yes
No
Please Explain
Please list findings of guilt, pleas of guilty, and pleas of nolo contendere, except minor traffic violations
EDUCATION
Are you a high school graduate?
Yes
No
Year of graduation
Name and address of high school
If you are not a high school graduate, do you have your GED?
Yes
No
Year and state of GED
Have you graduated or attended college?
Yes
No
What area of study and/or degree?
Do you have any license and/or certifications?
Yes
No
Please specify license(s) and/or certification(s)
Please indicate any of the following training you have:
CPR/First Aid
Yes
No
Medication Administration
Yes
No
Crisis Prevention Intervention
Yes
No
Certified Nursing Assistant
Yes
No
List any other skills you feel that are pertinent in why you should be hired for the position for which you are applying
EMPLOYMENT HISTORY
(1)
Company Name
Address
State
Zip Code
Phone Number
Dates of Employment
Position
Supervisor
Title
Duties
Reason for leaving
May we contact this past employer?
Yes
No
(2)
Company Name
Address
State
Zip Code
Phone Number
Dates of Employment
Position
Supervisor
Title
Duties
Reason for leaving
May we contact this past employer?
Yes
No
(3)
Company Name
Address
State
Zip Code
Phone Number
Dates of Employment
Position
Supervisor
Title
Duties
Reason for leaving
May we contact this past employer?
Yes
No
Please provide three (3) personal references not related to you or past employers
REFERENCES
(1)
Name
Relationship
Address
State
Zip Code
Phone
(2)
Name
Relationship
Address
State
Zip Code
Phone
(3)
Name
Relationship
Address
State
Zip Code
Phone
I
(print name), certify the answers I have provided are true. I hereby give Haney’s Heart-to-Heart In-Home Care LLC, permission to conduct a background screening for employment purposes.
Note: Any deliberate and/or false information can/will result in immediate disqualification.
Draw your signature
Clear
Date
Office Use Only
After conducting the Family Care Safety Register background screening this application is:
______Eligible _____Ineligible for employment with Haney’s Heart-to-Heart In-Home Care LLC.
Date: ______________________ Confirmation Number: ____________________ By: _______________________
Submit