Employment Application Employment Application Want to be a part of our team? Fill out the form below to apply! Credentials Needed Before Hiring: Upon Hiring: State ID or Drivers License Green Card/ USA Passport/ USA Birth Certificate Employment verification Interview Employee PPD or Chest X-Ray Test Social Security Card Professional License Lookup Give Orientation (Inservices on Hire) Physicals Professional Certificate Professional Certificate Verification Give Employee Handbook to Employee CPR Card Professional License Tax Forms Completed (W-4,W-9,VA-4) Give Employee Pay Schedule and Time Sheet Memorandum First Aid Card Resume Background Check Application Download Application Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Social Security NumberAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneIf you are under 18, can you furnish a work permit?YesNoEmployment Desired* Full Time Part Time Temp Seasonal Available Days* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Desired Hours*Postion*Start Date*Salary Desired*Are you employed now?*YesNoIf so may we inquire of your present employer?*YesNoEver applied for this company before?*YesNoIf so, when?Are you able to meet the attendance requirements of this postion?*YesNoHave you ever been bonded?*YesNoHave you ever been convicted of a felony in the past 7 years?*YesNoSuch conviction may be relevant if job related, but does not bar you from employment. If yes, explainDriver's License NumberStatePlease include your highest level of education, name and location of school, number of years completed, if you graduated and what subjects were studied.*Please summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with this company*List up to 3 previously held jobs. Please include start and end date, Name and address of employer, phone number, job title and reason for leaving*List 3 references not related to you and to whom you have known at least 1 year. Please include their name, address, phone and years known*List any foreign language(s) and if your skill level is read and write, read and speak, or speak onlyList an emergency contact. Please include their name, relationship to you, address and phone number*Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment included willingness on the part of the applicant or employee to agree to physical examination, polygraph, and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.* By checking this box I acknowledge that I have read and agree to the above statement It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service, if I have been employed. Furthermore, I understand that I am free to resign at any time, the Employer reserves the right to terminate my employment at any time with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary.* By checking this box I acknowledge that I have read and agree to the above statement I give the employer the right to investigate all police, driving and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information* By checking this box I acknowledge that I have read and agree to the above statement The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.* By checking this box I acknowledge that I have read and agree to the above statement Any controversy of any kind arisig between the parties under this areement or otherwise (or any agent, officer, director, or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or artbitrator from the designated company. Panels of mediators will notify the designated company, in writign, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act 9 U.S.C. Section 1-et seq. The parties herto stipulate that this agreement involves matters affecting interstate commerce.* By checking this box I acknowledge that I have read and agree to the above statement This application is effective for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application* By checking this box I acknowledge that I have read and agree to the above statement Type your full name as an electronic signature* Sworn Statement of Affirmation/Background Check Consent Section s32.1-162.9:1 of the code of Virginia requires that any applicant for employment with a licensed home care organization provide the Commissioner's representative with a sworn statement or affirmation disclosing (1) whether the applicant has a criminal conviction or is the subject of any pending criminal charged within or outside The Commonwealth of Virginia, and (2) whether the applicant has been the subject of a found complaint of child abuse or neglect within or outside the Commonwealth of Virginia. Any person making a materially flase statement on this form shall be guilty of a Class I misdemeanor Further dissemination of the information provided on this form is prohibited other than to the Commissioner's representative or a federal or state authority of court as many be required to comply with an express requirement of law for such further dissemination. Name* First Middle Last Email Maiden Nameif applicable Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you ever been convicted of a crime within or outside Virginia (but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law)?*YesNoIf yes, list all and explainAre you the subject of any pending criminal charges within or outside Virginia?*YesNoIf yes, explainHave you ever been the subject of a founded complaint of child abuse or neglect within or outside Virginia?*YesNoIf yes, explainI hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification* By checking this box I acknowledge that I have read and agree to the above statement Type your full name as an electronic signature* Criminal History Search Consent Form I have no pending charges within or outside the Commonwealth of Virginia and have had no prior convictions of an offense described in the Health and Safety Code which would bar or potentially bar employment as listed below.* By checking this box I acknowledge that I have read and agree to the above statement Criminal homicide Indecency with a child Solicitation of a child Arson Aggravated robbery Burglary & criminal trespass Weapons Public lewdness Public indecency Kidnapping & false imprisonment Agreement to abduct from custody Sale or purchase of a child Robbery Assaultive offenses Theft Fraud Indecent exposure A felony violation of a stature intended to control the possession or distribution of a substance (Virginia Controlled Substance Act) I understand that the home health agency is required to conduct a criminal history check before offering me employment. I, the undersigned, hereby authorize this agency to conduct and verify my criminal history by performing a criminal history check* By checking this box I acknowledge that I have read and agree to the above statement Type your full name as an electronic signature*
