Angelic Healthcare Services Employment Application

SECTION 2: EDUCATIONAL/PROFESSIONAL LICENSES/ CERTIFICATIONS/SKILLS
Highest Grade Completed: Grade School/ High School: 1 23456789 10 11 12*
Enter number
College/Grad 1 2 3 4 5 6
Enter number
Licenses/ Certifications:
Type
State Issued
Number
Date Expires
Type
State Issued
Number
Date Expires
List work skills for which you have been trained*
Have you served in the US Armed Forces?*

YesNo
if yes, are you in the reserve?

YesNo

SECTION 3: HEALTH
Any job offer is conditional and subject to the results of a post-offer medical examination. AHS mandates that all employees receive a physical prior to starting work at AHS. Are you willing to submit to a post-offer physical examination to determine if you can perform the job for which you have been offered employment safely and effectively?*

YesNo

SECTION 4: WORK HOURS AND SPECIAL CONDITIONS
Position you are applying for*
Work hours preferred*
Full-timePart-time
If part time, list days and hours of availability
Do you only want to work specific shifts?*

YesNo
If yes, do you prefer days, eves, nights?

DaysEvesNights
Are you willing to work weekends and/or holidays?*

YesNo
Date available to start*

MonthDayYear
Date
Rate which you expect hourly?*

SECTION 5: MARKETING AND PUBLIC RELATIONS
Please tell us how you heard about AHS:*

RadioTelevisionWebsiteFaceBookMailer
Person ? If so, who
Is this person employed at AHS?

YesNo
"LIKE" us on FaceBook for helpful information, job listings, events and give -a-ways & follow us on Twitter!

SECTION 6: WORK EXPERIENCE
Please list last three employers. References MUST BE VERIFIABLE. Your application can not be processed without verifiable employment references.
Employer # 1*
Start Date*

MonthDayYear
Date
End Date, if applicable

MonthDayYear
Date
If you are still employed at this company, type "present" in this field
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Position*
Duties *
Final pay rate*
Supervisor's name and title*
Did you resign, or were you fired/terminated?*

I resignedI was fired/terminated
If applicable, why did you resign?
If applicable, why were you fired/terminated?
Employer #2*
Start Date*

MonthDayYear
Date
End Date, if applicable

MonthDayYear
Date
If you are still employed at this company, type "present" in this field
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Position*
Duties*
Final pay rate*
Supervisor's name and title*
Did you resign, or were you fired/terminated?*

I resignedI was fired/terminated
If applicable, why did you resign?
If applicable, why were you fired/terminated?
Employer #3
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Position
Duties
Final pay rate
Supervisor's name and title
Did you resign, or were you fired/terminated?

I resignedI was fired/terminated
If applicable, why did you resign?
If applicable, why were you fired/terminated?

SECTION 7: PERSONAL REFERENCES
Please list three credible verifiable character references that are NOT related to you, that we may contact:
Reference #1*
Name
Relation*
Phone*
How do you know this person?*
How long have you known this person?*
Reference #2*
Name
Relation*
Phone*
How do you know this person?*
How long have you known this person?*
Reference #3
Name
Relation
Phone
How do you know this person?
How long have you known this person?

SECTION 8: DRUG FREE WORKPLACE
Angelic Healthcare Services will maintain an alcohol and drug free workplace in compliance with the Drug -free Workplace Act of 1990. Unlawful manufacture, use. possession. dispensation or distribution of alcoholic beverages and controlled substances as defined in the Control Substance Act (21.vs.c.802) in the workplace is prohibited.

SECTION 9: MANDATORY BACKGROUND SCREENINGS
It is mandatory that all applicants be registered with the Missouri Department of Health and Senior Services' Family Care Safety Registry. My signature below provides authorization for Angelic Healthcare Services LLC to conduct a pre- employment criminal record check/ background screening on me.

FCSR

The FCSR will be checked prior to hire and quarterly thereafter.

E-Verify

Angelic Healthcare Services LLC is required by the Department of Homeland Security to verify employment eligibility for all newly hired employees regardless of citizenship

EDL

The Employee Disqualification List (EDL) maintained by the Department of Health and Senior Services is a listing of individuals who have been determined to have:
- Abused or neglected a resident, patient, client, or consumer;
- Misappropriated funds or property belonging to a resident. patient. client. or consumer: or
- Falsified documentation verifying delivery of services to an in-home services client or consumer.
The EDL will be checked prior to hire and quarterly thereafter. If you have not resided in Missouri for 5 consecutive years prior to the date of this application for employment, Angelic Healthcare Services LLC is required to request a nationwide criminal background check for the purpose of determining if you have a prior criminal history in other states.

No applicant can be employed by Angelic Healthcare Services LLC until they pass a screening of the Employee Disqualifications List (EDL) and until Angelic Healthcare Services LLC has obtained a clean background check on the applicant from the Family Care Safety Registry (FCSR).

Anyone listed on the EDL will not, under any circumstances, be employed by Angelic Healthcare Services LLC.

If hired. the employee will have a copy of the background check and EDL placed in their personnel file. If any new listing appears on either of these background checks, the employee will no longer be able to be employed by Angelic Healthcare Services LLC.
Signature Authorization

I have read the above and understand my employment is conditionalpending the outcome of the Missouri Department of Health and Senior Services final decision and determination. I also grant permission to have my employkment eligibility verified through E-Verify, FCSR, EDL, and if necessary, perform a nationwaide criminal background check, now, and as required, while employed at Angelic Healthcare Services LLC. If it is determined that I have a closed record, I consent to a closed record check also.
APPLICANT'S SIGNATURE*

Clear
DATE*

MonthDayYear
Date

SECTION 10: MAJOR CONDITIONS OF EMPLOYMENT
In order to meet the needs of our clients/ patients/residents for 24 hour a day, 7 days a week care, I understand that I must perform work over a period of 40 hours a week before qualifying for overtime compensation. I understand that my shifts and days may be changed by the Director of Operations, Director of Clinical Services or his/her designee when necessary.

An offer of employment extended to you is conditional, subject to the results of a physical examination given by a MO state licensed physician, and must include the following health and mental well being:
- A diagnosis for tuberculosis,
- freedom from communicable diseases,
- freedom from open wounds, and
- ability to perform the essential functions described in the job description for which applicant is applying.
False statements or omitted material facts on this application, or on any resume, or given in an interview will result in disqualification from consideration or discharge.
I have read and understand the above, and agree to be bound by the 'MAJOR CONDITIONS OF EMPLOYMENT" stated on this application.

I agree to release any person or persons from any and all liability who provide information to facilitate the assessment of my qualifications for employment at AHS.

I authorize AHS to investigate my employment references and release AHS from any and all liability resulting from such investigation.

Upon my seperation, I authorize the release of reference information on my dates of employment, job titles, job duties, work performance, and type of and reason for separation.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Employment Application

SECTION 1: PERSONAL

SECTION 2: EDUCATIONAL/PROFESSIONAL LICENSES/ CERTIFICATIONS/SKILLS

SECTION 3: HEALTH

SECTION 4: WORK HOURS AND SPECIAL CONDITIONS

SECTION 5: MARKETING AND PUBLIC RELATIONS

SECTION 6: WORK EXPERIENCE

SECTION 7: PERSONAL REFERENCES

SECTION 8: DRUG FREE WORKPLACE

SECTION 9: MANDATORY BACKGROUND SCREENINGS

SECTION 10: MAJOR CONDITIONS OF EMPLOYMENT