DHSCS Employment Application

Divine Heart Supportive Community Services LLC

"Providing Divine Quality Care to You"

424 Investor Place Suite 108, VA BCH VA 23452

757-748-0424(office)

804-404-9532(fax)

www.divineheartscs.com

hr@divineheartscs.com

Date*

Todays Date

Full Name*

First NameLast Name

Middle *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Position Applying For*

Home Phone Number*

Please enter a valid phone number.

Cell Phone Number*

Please enter a valid phone number.

Email Address*

example@example.com

Date of Birth*

Social Security Number*

Gender*

FemaleMale

What languages do you speak?*

Preferred Language?*

Name & Phone Number of Person to contact in the event of an emergency:

Emergency Contact Full Name #1*

Relationship Type*

Phone Number*

Please enter a valid phone number.

Emergency Contact Full Name # 2*

Relationship type*

Phone Number*

Please enter a valid phone number.

Level of Education (High School Diploma, GED, College etc) *provide a copy**

File Upload

Do you have current First Aid Certification*

YesNo

Do you have current CPR Certification (copy required)*

YesNo

Upload CPR Certificate if Applicable

COVID-19 Vaccinated*

YesNo

Upload COVID Card, if Applicable

40 Hour PCA Certification

Upload 40 PCA Certification, if Applicable

Availability*

Full - TimePart - TimePRN - As neededFloater

Days Available*

Describe times availability (for example - 7:00am-7:00pm M,W, F and Saturday)*

What is the minimum number of hours you will work in one day?*

What is the maximum number of hours you will work in one day?*

When can you start working?*

Do you have work limitation?*

YesNo

List any work limitations, if applicable

if yes, explain in details*

LOCATIONS:*

Do you have reliable transportation to and from work site?*

Do you have adequate vehicle insurance?*

Are you willing to transport clients in your private vehicle? (Transportation Waiver form)*

NoYes

Have you ever been investigated for abuse, neglect or domestic violence? Yes*

NoYes

If "yes", explain*

Do you have a criminal background? Do you have any upcoming criminal cases pending? If yes, explain:*

NoYes

If yes, explain*

Work experience*

Company Name*

*Most Recent Employer related to Home Care Services*

Address*

Telephone No*

Supervisor's Name*

Position Held*

Length of Employment*

Reason for Leaving*

File Upload (Resume)

References

Personal Reference #1:(name & number)*

Full Name

Relationship Type (friend or co-worker)*

Full Name

Professional Reference #2:*

Telephone No. *

Relationship Type (friend or co-worker)*

CERTIFICATION

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Divine Heart Supportive Community Services LLC DBA Divine Heart SCS LLC and I hereby release and discharge any of the above and Divine Heart SCS LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with Divine Heart Supportive Community Services LLC. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check.

I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.

Applicant's Signature*

Date*

Date

Please verify that you are human*

"Providing Divine Quality Care to You"

Work Experience