Application For Employment

Hourly Availability:

( Specify the EXACT day and time that you are available to work ex: (9am-5pm)
Please check the days you are available and then enter the time below*

SundayMondayTuesdayWednesdayThursdayFridaySaturdayN/A
Sunday Availability*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Monday Availability*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Tuesday Availability*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Wednesday Availability*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Thursday Availability*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Friday Availability*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Saturday Availability*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option

Driver's License Upload

Emerest requires copies of your driver's license. Please upload a picture of it here. You can take a photo of it OR upload a photo from your phone or device below.
Take Photo
File Upload

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Before proceeding please be sure you have uploaded a copy of your driver's license

Social Security Card Upload

Emerest requires a copy of your social security card. Please upload a picture of it here. You can take a photo of it OR upload a photo from your phone or device below.
Take Photo
File Upload

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Before proceeding please be sure you have uploaded a copy of your social security card.

Car Insurance and Registration Upload

Emerest requires copies of your car insurance and registration. Please upload a picture of it here. You can take a photo of it OR upload a photo from your phone or device below.
Before proceeding please be sure you have uploaded a copy of your car insurance and registration.
Take Photo of Car Insurance
Take Photo of Car Registration
File Upload of Car Insurance

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File Upload of Car Registration

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Emergency Contact Information
Notify in Case of Emergency#1:
Emergency Contact Name*

First NameLast Name
Relationship
Cell Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Notify in Case of Emergency#2:
Emergency Contact Name*

First NameLast Name
Relationship
Cell Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment Background Check Consent
We have retained SappHire Check to conduct criminal background checks on our behalf. SappHire will send you an email from Support@sapphirecheck.com or a text message from 877-232-3945 for you to complete the background check form. Please complete the form as quickly as possible so that the hiring process can proceed without delay. Please note that when completing the background check submission form you will be asked to certify that the statements you make on the application are true and complete to the best of your knowledge and are made in good faith, and that you understand that if you knowingly make any misstatements of fact, you are subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Please note Emerest takes all necessary precautions to protect your SSN and all other personal information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Present Employer
Position
Supervisor's Name
Supervisor's Phone
Please enter a valid phone number.
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Phone
Please enter a valid phone number.
Disclosure Regarding Background Investigations On You

Emerest Home Care of Connecticut LLC ("the Company") may obtain "consumer reports" about you from a consumer reporting agency for employment purposes. A "consumer report" is a background screening report that contain information regarding your criminal history, sex offender registry status, credit history, employment history, education history, social media activity, driving history, drug test results, professional licenses, and other information about you. It may bear upon your character, general reputation, personal characteristics and/or mode of living.

AUTHORIZATION REGARDING BACKGROUND INVESTIGATION

By signing below, I acknowledge receipt of the following separate documents (and
certify that I have read and understood them):
• DISCLOSURE REGARDING BACKGROUND INVESTIGATION ON YOU;
• A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT; •ADDITIONAL NOTICE REGARDING INVESTIGATIVE CONSUMER REPORTS
ON YOU;
• ADDITIONAL STATE LAW NOTICES.
By signing below, I authorize Emerest Home Care of Connecticut LLC
(“the Company”) to obtain “consumer reports” and “investigative consumer reports” about me for employment purposes at any time during the hiring process and throughout my employment, if applicable.

ADDITIONAL NOTICE REGARDING INVESTIGATIVE CONSUMER REPORTS ON YOU

Emerest Home Care of Connecticut LLC (“the Company”) may also
request an “investigative consumer report” on you from a consumer reporting agency. An “investigative consumer report” is a background screening report generated through personal interviews with sources such as your neighbors, friends, or associates. The consumer reporting agency that may prepare an “investigative consumer report” on you for the Company is Sapphire Check LLC, 117 Ditmas Avenue, Brooklyn, NY 11218, 888-993-4473. The information contained in an “investigative consumer report” may bear upon your character, general reputation, personal characteristics, and/or mode of living.
Please be advised that the nature and scope of the most common form of “investigative consumer report” that may be ordered by the Company is an investigation into your employment history. During such an investigation, Sapphire Check LLC may askquestions about your employment history to certain knowledgeable individuals and provide response information to the Company. Note: You have the right to request additional information regarding the nature and scope of any “investigative consumer report” ordered by the Company on you. You may do so by contacting the Company.

Applicant’s Statement

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the company.

I/We declare that all information given in this application is true and correct. I/We authorize Sapphire Background Check on behalf of the employer to verify and obtain a complete consumer Credit report, Driving records, Criminal records and Employment verification, and supply information obtained to their clients. This information is not privileged. This authorization shall be valid in original or fax copy form.
Date

MonthDayYear
Date
Signature*

Clear

Comprehensive Background Check Form Pursuant to Connecticut Agencies Regs S. 20-670-2
1. Have you been convicted of a crime involving violence or dishonesty in a state court or federal court in any state?*

YesNo
If yes, please explain:
2. Have you been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?*

YesNo
If yes please explain:
Applicant’s Statement

I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.
Date*

MonthDayYear
Date
Signature*

Clear

Drug Screening Acknowledgement Form
It is the policy of Emerest Home Care of Connecticut LLC, to conduct urinalysis testing at any time during employment, including pre-employment, annually thereafter, after an incident or accident, or randomly as deemed by management. Positive test results or failure to show for testing will result in disciplinary action up to and including termination of employment.
I,   First Name   Last Name have read and understood the Drug Screening Policy provided to me by Emerest Home Care of Connecticut LLC.


Date*
Signature*

Clear

Medical Benefits Election Form
SPECIAL ENROLLMENT RIGHTS:

If you or your children lost other coverage…
If you are declining enrollment for yourself or your children because of other health
insurance or group health plan coverage, you may be able to enroll yourself and your
children in this plan if you lose eligibility for that other coverage (or if an employer stops contributing toward that other coverage). However, you must request enrollment within 30 days after your other coverage ends or your children’s other coverage ends (or after the employer stops contributing toward the other coverage).

If you have a new dependent…
If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your children. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

If you or your children are determined to be eligible for premium assistance…
If you or your children are eligible for Medicaid or CHIP and you’re also eligible for
health coverage from Emerest Home Care, your state may have a premium assistance program that can help pay for your coverage, using funds from the Medicaid or CHIP programs.
If you or your dependents are already enrolled in Medicaid or CHIP, contact your State
Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State
Medicaid or CHIP office or dial 1-877-KIDS NOW or visit www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your children are eligible for premium assistance under Medicaid or CHIP, Emerest Home Care will allow you to enroll in its health coverage (if you aren’t already enrolled). You must request coverage within 60 days of being determined eligible for premium assistance.

For more information please contact your administrator.
Choose one of the following options:*

I would like employee-only health coverage from Emerest Home Care of Connecticut, effective as of your date of hire for a monthly charge of $70. Deductions will be made the first paycheck of each month. If you terminate employment mid-month, deductions or costs will not be adjustedI would like Family health coverage from Emerest Home Care of Connecticut effective your date of hire. Family coverage includes Spouse and Dependent(s) for a monthly charge of $90. Deductions will be made the first paycheck of each month. If you terminate employment mid-month, deductions or costs will not be adjustedI do not want any health coverage from Emerest Home Care of Connecticut
If you are declining health care coverage please choose one of the following:*

I have health coverage that I purchased from a health care marketplace or exchangeI have health coverage from Medicaid or Medicare.I have other health coverageOther: Please give a reason in the box below:
Date*

MonthDayYear
Date
Signature*

Clear

ACKNOWLEDGEMENT OF RECEIPT OF THE EMEREST HOME CARE OF CONNECTICUT EMPLOYEE HANDBOOK
A copy of this manual will be emailed to you when you submit this form
I have received and read my copy of the employee handbook, had an opportunity to ask
questions and I am reasonably familiar with its terms and conditions. In consideration for my employment, and my continued employment, I agree to abide by the rules, regulations and policies of the Company as set out in the handbook, including all future editions. As a result of reading the handbook, I specifically understand the following:
1. The handbook does not create a contract of employment between the company and myself, but is merely a set of general guidelines for the implementation of personnel policies. I understand that no representative of the company, other than the Human Resource Director has the authority to modify and provision of the handbook or enter into any contract for employment of to make any agreement contrary to the policies included within this handbook. I understand that I am employed on an at-will basis and that my employment may be terminated at any time, either by me or the Company, with or without cause.
2. I will seek clarification from my Human Resource Director if there is any policy or
provision in the handbook that I do not understand.
3. I also understand that these policies and procedures are continually evaluated and may be amended, modified or terminated at any time.
Name*

First NameLast Name
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Application For Employment

Hourly Availability:

Live In Availability:

Driver's License Upload

Social Security Card Upload

Car Insurance and Registration Upload

Emergency Contact Information

Notify in Case of Emergency#1:

Notify in Case of Emergency#2:

Employment Background Check Consent

Comprehensive Background Check Form Pursuant to Connecticut Agencies Regs S. 20-670-2

Drug Screening Acknowledgement Form

Medical Benefits Election Form

ACKNOWLEDGEMENT OF RECEIPT OF THE EMEREST HOME CARE OF CONNECTICUT EMPLOYEE HANDBOOK