Employment Application

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Employment Application

Applicants are not required to give information prohibit by federal, state/provincial or local Law

Date

Are you over the age of 18:

Yes

DOB:

Name

Current Address

Previous Address ( if current address is less than 5 years)

Home phone

Cell phone

Has your driver's license ever been suspended or revoked?

Yes

Have you ever entered a plea of guilty or nolo contendere to, or been convicted of anything other than a minor traffic accident?

Yes

If so, please explain

Have you ever been bonded?

Yes

Have you ever been denied bond coverage?

Yes

Are you a U.S. citizen?

Yes

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

Yes

Have you used any alias?

If YES, List ALL aliases you have used(include maiden names, married names, and other legal name changes).

Have you used any other social security numbers?

Yes

If Yes, list All the social security numbers you have ever used

Criminal convictions, finding of guilty, pleas of guilty, and pleas of nolo contendere(except minor traffic violations?

Yes

If YES, list All criminal convictions, findings of guilty, and pleas of nolo contendere AND the state in which this occurred. Do not list minor traffic offenses such as speeding and parking tickets.

How did you learn about us?

Advertising

Employment Agency

Friend

Relative

Other

Have you been employed with us before?

If Yes, give date(s)

Are you currently employed?

Yes

If yes, may we contact your present employer?

Yes

Date of Employment:

Reason for leaving

Are you eligible for rehire?

Yes

Are you available Fulltime Part time? What days are you available?

Fulltime

Part time

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DAYS AND TIMES OF AVAILABILITY

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

On what date would you be available to begin work?

What starting salary do you expect? per hour

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? (Proof of Citizenship or Immigration status will be required upon employment)

Yes

Are you currently registered with the Family Care Safety Registry?

Yes

If no, do you consent to become registered with the Family Care Safety registry? (Failure to check "Yes: for consent will result in a denial of Employment)

Yes

Do you have a disqualifying event that would be included in the Family Care Safety registry?

Yes

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No Applicant can be employed by Heavenly Angels Home Healthcare Servinces, LLC until they pass a screening of the Employee Disqualification List (EDL). Until Heavenly Angels Home Healthcare Services, LLC has obtained a clean background check on the application from the Family Care Safety Registry (FCSR). There will be a $15.00 non-refundable registration fee for employees to be screened and registered.

If an Applicant has certain offenses listed on the FCSR background check, the applicant may apply for a "Good Cause Waiver" to the Missouri Department of Health Department of Health and Senior Services (DHSS).

DHSS may grant (approved) a "Good Cause Waiver" at their discretion.

Anyone listed on the EDL will not, under any circumstances, be employed by Heavenly Angels Home Healthcare Services, LLC. The FCSR will be checked twice a year. The EDL will be checked four times a year (this includes the checks done through the FCSR). if any new listings appear on either of these background cheeks, the attendant will no longer be able to be employed by Heavenly Angels Home Healthcare Services, LLC.

The Employee will recieve a copy theses background checks from DHSS (FCSR) at least twice a year.

Do you consent for a pre-employment criminal record check?

Yes

Do you consent to open background checks, pursuan to SECTION 610.120 RSMo?

Yes

Are you presently employed with another Home Health Agency?

Yes

If yes, who is you present employer

Are you related either by marriage or blood to a client receiving our services?

Yes

Have you ever been a resident of or employed in another state?

Yes

If yes, where and what date

This job requires consistent regular and punctual attendnace; can you meet this requirement?

Yes

Have you served in the U.S, Military:

Yes

If yes, Please provide the following information:

Branch of Service

Date of Service

Rank of Discharge:

Type of Discharge:

Was Discharge Honorable?

Yes

If not explain:

Have you ever had any job-related training in the United States Military?

Yes

Describe and date below any non-paid volunteer work experience (exclude organizations, the name of charter of which would indicate the race, sex, religion, national origin or disability of its members)

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DRIVERS INFORMATION

This job requires you to have a dependable vehicle. Are you currently in possession of one ?

Yes

Are you currently in possession of Automobile Insurance that meets the statutory insurance requirements for the State of Missouri?

Yes

Is this Insurance presently in effect?

Yes

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EMPLOYMENT HISTORY

1. Employer Name

Employer Address

Supervisor/Manager Name

Phone Number

Dates Employed From

Wages: $

Per

Hour

Week

Year

Description of Current Job

Reason For Leaving

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2. Employer Name

Employer Address

Supervisor/Manager Name

Phone Number

Dates Employed From

Wages: $

Per

Hour

Week

Year

Description of Current Job

Reason For Leaving

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3. Employer Name

Employer Address

Supervisor/Manager Name

Phone Number

Dates Employed From

Wages: $

Per

Hour

Week

Year

Description of Job

Reason for Leaving

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EDUCATION

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Elementary School

School Name/Location

# Years Completed

Date of Attendance

Diploma/Degree

Describe Course of Study

Graduate

Yes

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High School

School Name/Location

# Years Completed

Date of Attendance

Diploma/Degree

Graduate

Yes

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Undergraduate/ College/ University/ Technical

School Name/Location

# Years Completed

Date of Attendance

Diploma/Degree

Describe Course of Study

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LICENSURE/CERTIFICATIONS

Position

Registered Nurse (RN)

License Number

Date Received

Date Expired

Position

Licensed Practical Nurse (LPN)

License Number

Date Received

Date Expired

Position

Nurse's Assistant (NA)

License Number

Date Received

Date Expired

New Field:

Home Health Aide (HHA)

License Number

Date Received

Date Expired

Position

Certified Medication Technician (CMT)

License Number

Date Received

Date Expired

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EMPLOYMENT REFERENCE (1)

ALL EMPLOYESS MUST HAVE 2 EMPLOYMENT REFERENCES

Company Name

Company Representative Name

Company Representative Title

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Dates of Employment

Start Date

End Date

Company Address

Company Telephone Number

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FOR OFFICE TO COMPLETE

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Employment Reference Questions

What title did the individual hold within your organizations?

Would you rehire this individual?

Yes

What was the reason for leaving your organization?

Comments

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Employment references must be able to be verified. if not, you will need to give additional references.

References Checked by

Signature

Date

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EMPLOYMENT REFERENCE (2)

Company Name

Company Representative Name

Company Representative title

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Dates of Employment

Start Date

End Date

Company Address

Company Telephone Number

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FOR OFFICE TO COMPLETE

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Employment Reference Questions

What title did the individual hold within your organizations?

Would you rehire this individual?

Yes

What was the reason for leaving your organization?

Comments

Free Text

Employment references must be able to be verified. if not, you will need to give additional references.

References Checked by:

Signature

Date

Have questions? Send us your queries and we’ll be in touch!

"She believed she could…and she did"

Phone: (314) 325-5465

Business Hours: Tuesday - Thursday: 10:00 AM-2:00 PM