Employment Application · Family 1st Homecare

Applicant Information

Last Name *

First Name *

M.I.

Date of Birth *

Other Names Used (alias or maiden)

Year(s) Those Names Were Used

Current Address

Street Address *

Apartment / Unit #

City *

State *

ZIP *

Permanent Address Same as current address

Street Address

Apartment / Unit #

City

State

ZIP

Former Address (if less than 3 years at current address)

Contact Details

Cell Phone *

Home Phone

Other Phone

E-mail Address *

Social Security No. *

Position & Availability

Position Applied For *

Date Available *

Desired Salary

Work Eligibility

Are you eligible to work in the United States? *

Yes No

Are you a citizen of the United States? *

Yes No

Permanent Resident (Green Card) Number

Have you ever worked for this company? *

Yes No

If so, when?

Public Assistance

Do you currently receive assistance from the Department of Public Welfare? *

Yes No

Are you currently receiving Unemployment Compensation? *

Yes No

Are you currently enrolled in the Ways to Work Program? *

Yes No

Are you currently receiving assistance from any County Assistance Agency? *

Yes No

Background Disclosures

If you answer Yes to any question below, please provide the date, the conviction or action, and the final outcome in the fields that appear.

Have you ever been convicted of a felony or misdemeanor? *

Yes No

Date

Conviction

Outcome

Do you currently have any pending felony or misdemeanor charges? *

Yes No

Date

Conviction

Outcome

Have you ever pleaded guilty, been convicted of, accepted ARD or a similar monitored program, or pleaded nolo contendere (no contest) to any felony or misdemeanor offenses? *

Yes No

Date

Conviction

Outcome

Have you ever been involved in a malpractice claim(s) (including dismissed actions)? *

Yes No

Date

Action

Outcome

Have you ever had any disciplinary action against any of your licenses/certifications? *

Yes No

Date

Action

Outcome

Has any monetary payment ever been made by you or on your behalf because of alleged medical malpractice? *

Yes No

Date

Action

Outcome

Are there currently any pending medical malpractice claims or settlements involving yourself? *

Yes No

Date

Action

Outcome

Has your professional liability insurance coverage ever been denied, limited, or canceled by any insurance company? *

Yes No

Date

Action

Outcome

Has your current liability insurance carrier excluded any specific procedures from your insurance coverage? *

Yes No

Date

Action

Outcome

Have you ever had a warrant issued for your arrest? *

Yes No

Date

Action

Outcome

Education

Complete the rows that apply to you. High school details are required.

High School *

School Name *

Address

From

To

Did you graduate?

Yes No

Degree / Diploma

College

School Name

Address

From

To

Did you graduate?

Yes No

Degree / Diploma

Graduate School

School Name

Address

From

To

Did you graduate?

Yes No

Degree / Diploma

Voc/Technical

School Name

Address

From

To

Did you graduate?

Yes No

Degree / Diploma

Other

School Name

Address

Additional Training

Academic honors, awards or other recognitions

Other training or skills (seminars, activities, etc.)

Military Service

Leave this section blank if it does not apply to you.

Branch

From

To

Rank at Discharge

Type of Discharge

If other than honorable, please explain

Licensure & Certification

Please bring photocopies of all licenses you hold to your interview.

Professional License(s)

Certification / Registration(s)

Accreditation(s)

License Details

License 1 - State

License 1 - Type

License 1 - Certif./Registr. #

License 2 - State

License 2 - Type

License 2 - Certif./Registr. #

Professional References

Please list three professional references. The first reference is required.

Reference 1 *

Full Name *

Relationship *

Company

Phone *

Address

Reference 2

Full Name

Relationship

Company

Phone

Address

Reference 3

Full Name

Relationship

Company

Phone

Address

Previous Employment

Start with your most recent employer. The first entry is required.

Employer 1 *

Company *

Phone

Address

Supervisor

Job Title *

Starting Salary

Ending Salary

From *

To *

Responsibilities

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Employer 2

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

From

To

Responsibilities

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Employer 3

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

From

To

Responsibilities

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes No

Professional Liability Insurance

Complete if you carry (or have carried) professional liability insurance.

Present Carrier

Carrier

Policy Number

Phone Number

Address

City, State

Effective Date

Expiration Date

Previous Carrier

Carrier

Policy Number

Phone Number

Address

City, State

Effective Date

Expiration Date

Background Check Identification

This information enables us to properly identify you in the event adverse information is found during the background search.

Gender

Race (optional)

Driver's License / ID #

Issuing State

Please provide me with a copy of my background investigation *

Yes No

Disclaimer & Acknowledgements

Read each statement and type your initials in the box beside it.

I understand and agree that the acceptance of this application by the company does not constitute a promise that I will be hired. I further understand that the company does not guarantee employment for any specific length of time and, therefore, agree that if I am hired my employment may be terminated by either the company or me at any time without cause or notice.

Initials *

If I am employed by the company, I agree to abide by the rules and regulations of the company. I fully understand that all records pertaining to my employment are to remain the property of the company, and that hours of work and other working conditions are subject to change at the organization's discretion.

Initials *

I certify that I fully understand all requests for information contained in this application, and I certify that the information supplied by me, on this form and elsewhere in conjunction with obtaining employment, is complete and correct to the best of my knowledge and hereby grant the company permission to verify such answers and investigate all references including a criminal history check with local, state and federal agencies as well as a background check for fraud and abuse with the Cumulative Sanction Report and National Practitioner Databank. I understand that any false or misleading statements, omission, or misrepresentation on this application will be considered sufficient cause for rejection of this application or for dismissal, if such information or omission is discovered subsequent to my employment.

Initials *

I authorize the employers, schools, or persons named above to give any information regarding my previous employment, character, general reputation, and other personal characteristics, together with any information regarding me, whether or not it is in their records. I understand that under the Federal Fair Credit Reporting Act, I have the right to make written request within a reasonable period of time for the complete and accurate disclosure by the company of the nature and scope of any credit investigation requested. I hereby release the company, employers, schools, or persons from all liability for any damage resulting from issuing the information. I further certify that I have not entered into any agreement with any previous employer or other organization that would prevent or restrict my employment with the company at this time or in the future.

Initials *

In consideration of my employment, I agree to submit to pre-placement screening and periodic physical examinations and evaluations, including, but not limited to, diagnostic testing, as the company, from time to time, deems reasonably necessary to determine my fitness to perform the work for which I was hired. I understand that, as a condition of employment, I may be required to submit to testing for the illegal use of drugs. If the testing reveals evidence of the illegal use of drugs, any offer(s) of employment extended to me will be unconditionally revoked regardless of whether I have or have not begun employment.

Initials *

I swear and affirm that I have reviewed the prohibited offenses contained in Act 169 of 1996 Amended by Act 13 of 1997 and Act 14 of 1997. I further attest that I am not disqualified from employment which excludes individuals with convictions for prohibitive offenses. If the criminal background check reveals evidence of any prohibited offense, any offer(s) of employment extended to me will be unconditionally revoked regardless of whether I have or have not begun employment.

Initials *

I understand and agree that when my employment is terminated, I must return all property in my custody belonging to my employer. To be employed, I understand I must be lawfully authorized to work in the United States and that I must show documented proof of authorization. The company is an Equal Opportunity Employer.

Initials *

Waiver and Release of Information

I, the undersigned consumer, hereby authorize Family 1st and its affiliated companies and/or subsidiaries (hereinafter known as The Company), by and through any Consumer Reporting Agency ("CRA") or any federal, state, local law enforcement agency to procure a consumer report and/or investigative consumer report on me for employment purposes. These reports may include, but are not necessarily limited to, information regarding my personal characteristics, means and manner of living, character and general reputation, and may be obtained through one or more of the following sources: employment and education verifications; my personal credit history based on reports from any credit bureau; personal references; personal interviews; driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and any other public records.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject upon my written request to any CRA, if such request is made within a reasonable time after the date hereof. I also understand that I may receive a written summary of my rights under 15 U.S.C. Section 1681 et. seq. and Cal. Civ. Code Section 1786.

I also authorize any person, business or governmental agency that may have information relevant to the above, including but not limited to, all courts, public agencies, law enforcement agencies and credit bureaus, to disclose the same to THE COMPANY or any CRA, regardless of the manner in which such person, business entity or governmental agency obtained the information itself.

I hereby release THE COMPANY, any CRA and any and all persons, business entities and governmental agencies providing information, whether public or private, from any and all liability, claims and/or demands, by me, my heirs or others making such claim or demand on my behalf, for providing the consumer report(s) and/or investigative consumer report(s) authorized by me herein.

I understand that this Release and Authorization shall remain in effect for the duration of my employment with THE COMPANY, and that THE COMPANY may obtain additional consumer and/or investigative consumer report(s) on me.

Additionally, I hereby authorize THE COMPANY to investigate any incidents of workplace misconduct made against or involving me both during and after the term of my employment with THE COMPANY.

A photocopy or fax of this authorization shall be deemed an original and shall be accepted as such by every person.

I hereby certify that the information contained on this release and authorization form is true and correct as of the date hereof, and that my application or employment will be terminated based on any false, omitted or fraudulent information.

I have read and I agree to the Waiver and Release of Information above, and I certify that all information in this application is true and complete to the best of my knowledge. *

Electronic Signature

Sign below using your mouse or finger *

Your signature is stored with your packet.

Printed Name *

Date *

After you submit, your completed employment packet is generated as a PDF that you can download immediately. Please print it and bring it with you to your interview.