BELLA VITA EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

Please read "Applicant Note" below. Complete all pages of this application. Print clearly. Incomplete or illegible applications may not be accepted If more space is needed to complete any question, use comments section on the back. Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with our Home Care Agency. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins. terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age. disability. or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

PERSONAL INFORMATION
NAME:*
DATE:

MonthDayYear
Date
PHONE:*
E MAIL:*
example@example.com
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SOCIAL SECURITY NUMBER (SSN):
DATE AVAILABLE:

MonthDayYear
Date
POSITION APPLIED FOR:
EMPLOYMENT DESIRED:

FULL-TIMEPART-TIMESEASONAL
DESIRED PAY:
HOURLYSALARY

EMPLOYMENT ELIGIBILITY
ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S.?

YESNO
HAVE YOU EVER WORKED FOR THIS EMPLOYER?

YESNO
IF YES, WRITE THE START AND END DATES

MonthDayYear
Date
HAVE YOU EVER BEEN CONVICTED OF A FELONY?

YESNO
IF YES, PLEASE EXPLAIN

EDUCATION

HIGH SCHOOL
HIGH SCHOOL
CITY / STATE
FROM
TO
DID YOU GRADUATE?

YESNO
DIPLOMA

COLLEGE
COLLEGE
CITY / STATE
FROM
TO
DID YOU GRADUATE?

YESNO
DEGREE/CERTIFICATE

OTHER EDUCATION
OTHER EDUCATION
CITY / STATE
FROM
TO
DID YOU GRADUATE?

YESNO
DEGREE/CERTIFICATE

OTHER EDUCATION
OTHER EDUCATION
CITY / STATE
FROM
TO
DID YOU GRADUATE?

YESNO
DEGREE/CERTIFICATE

PREVIOUS EMPLOYMENT
Fill out as much about your past employment as you're able to.

EMPLOYER 1
EMPLOYER 1
Company / Individual
JOB TITLE
PHONE
Please enter a valid phone number.
EMAIL
example@example.com
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
STARTING PAY:
ENDING PAY:
RESPONSIBILITIES
REASON FOR LEAVING

EMPLOYER 2
EMPLOYER 2
Company / Individual
JOB TITLE
PHONE
Please enter a valid phone number.
EMAIL
example@example.com
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
STARTING PAY:
ENDING PAY:
RESPONSIBILITIES

EMPLOYER 3
EMPLOYER 3
Company / Individual
JOB TITLE
PHONE
Please enter a valid phone number.
EMAIL
example@example.com
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
STARTING PAY:
ENDING PAY:

EMPLOYER 4
EMPLOYER 4
Company / Individual
JOB TITLE
PHONE
Please enter a valid phone number.
EMAIL
example@example.com
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
STARTING PAY:
ENDING PAY:
RESPONSIBILITIES
REASON FOR LEAVING

EMPLOYER 5
EMPLOYER 5
Company / Individual
JOB TITLE
PHONE
Please enter a valid phone number.
EMAIL
example@example.com
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
STARTING PAY:
ENDING PAY:
RESPONSIBILITIES

EMPLOYER 6
EMPLOYER 6
Company / Individual
JOB TITLE
PHONE
Please enter a valid phone number.
EMAIL
example@example.com
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
STARTING PAY:
ENDING PAY:

REFERENCES (PROFESSIONAL ONLY)

REFERENCE 1
NAME
RELATIONSHIP
COMPANY
TITLE
E MAIL
example@example.com
PHONE

REFERENCE 2
NAME
RELATIONSHIP
COMPANY
TITLE
E MAIL
example@example.com
PHONE

REFERENCE 3
NAME
RELATIONSHIP
COMPANY
TITLE
E MAIL
example@example.com
PHONE

BACKGROUND CHECK CONSENT
IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK?

YESNO
DISCLAIMER
Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered

Please complete each section EVEN IF you decide to attach a resume.

I. the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated
SIGNATURE

Clear
DATE

MonthDayYear
Date
PRINT NAME
Have you been charged/convicted of a Felony or Misdemeanor or served time?

YESNO

If yes, please describe:

	Incident	City/ State	Charge
1
2

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

YESNO
APPLICANT NOTICE:
It is illegal in Philadelphia for employers to ask about your criminal background during the job application process.

Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depend on the results of your background check

Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting time of incarceration Arrests that did not lead to conviction cannot be used in any employment decisions. If your background check reveals a conviction, the employer must consider: The type of offense and the time that has passed since it occurred. Its connection to the job you're applying for; and Your job history, character references, and any evidence of rehabilitation Employers can reject you based on your criminal record ONLY if you pose an unacceptable risk to the business or to other people. If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision. You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation

APPLICANT CERTIFICATION AND RELEASE:
I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools. companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations Ialso understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this of application is not a contract of employment. My employment is contingent upon confirmation credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
APPLICANT SIGNATURE

Clear
DATE

MonthDayYear
Date

DIRECT CARE WORKER AVAILABILITY FORM
Please complete the following schedule and provide times that you are able to work for BVCS. We provide services 24 hours a day. 7 days a week. How you complete this form is especially important. The work hours that are provided for you by BVCS are driven by two primary business issues; the needs of the Consumers and your availability to work.
TOTAL REQUESTED HOURS PER WEEK:
Ideal
Minimum
Maximum
**I understands that the more I am available to work the greater likelihood that my hours request will be met.

	Start Time	End Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

ADDITIONAL AVAILABILITY:

	Yes	No
Are you willing to do temporary fill-in hours?
Are you available to be On-Call for additional income?
Are you willing to work with Consumers who smoke?
Are you willing to work with Consumers who have pets?

This sheet designates the times that I am committing myself to be available to work for BVCS. By signing this sheet, I acknowledge that the decision to hire me will be based in part on the above availability. I agree any changes to my availability must be approved and signed by my supervisor. I understand that there is no guarantee of hours if I am offered a position with BVCS. I understand that affect this goal including my availability, Consumer requests, my stalls, and my ability to please the Consumer to whom I am assigned. Nothing in this statement is to be construed as a direct, implied or inferred contract of employment. I understand I am not authorized to provide medical care independently and agree that if a medical emergency arises while I am with a Consumer, I will call 911 and follow their instructions accordingly.

it can take time to reach and sustain my desired number of hours per" week and that multiple factors
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

EMPLOYMENT APPLICATION

PERSONAL INFORMATION

EMPLOYMENT ELIGIBILITY

EDUCATION

PREVIOUS EMPLOYMENT

REFERENCES (PROFESSIONAL ONLY)

BACKGROUND CHECK CONSENT

DISCLAIMER

APPLICANT NOTICE:

APPLICANT CERTIFICATION AND RELEASE:

DIRECT CARE WORKER AVAILABILITY FORM

TOTAL REQUESTED HOURS PER WEEK:

ADDITIONAL AVAILABILITY: