Opulent Employment Application

Opulent Home Care

2727 Paces Ferry Rd SE, Suite 750, Atlanta, GA 30339

Tel: (678)206-7255

Email: info@opulenthomecares.com

Date

Name

Last

Address: Street, City, State, Zip Code

Phone Number

Please enter a valid phone number.

Email Address

Social Security Number

How did you hear about us?

Type of employment/ pay desired

Please Specify Days and Hours Available

Position applied for: CNA, LPN, RN, Other

Are you legally eligible to work in the US?

YesNo

Are you available to work Call Outs, if needed?

YesNo

Have you ever been employed at our company?

YesNo

If yes, when?

Why did you leave?

FYI: Conviction will not be a deciding factor in continuing the pre-screening process or potential employment opportunities.

Have you been convicted of a crime in the last seven (7) years? If yes, please explain:

Educational Background: Please Answer the Following Questions List previous educational history:

Previous Educational History

Document Checklist

Do you have any friends or family employed at this location?

YesNo

If yes, please explain

During the hiring process, do you agree to provide a criminal background check?

YesNo

During the hiring process, do you agree to provide a Motor Vehicle Record?

YesNo

What do you think is the most difficult part of caregiving or customer service work?

Ms. Jones asks you to apply BENGAY muscle rub on her back, what would you do?

In what situations do we provide services not listed in the SERVICE PLAN?

What is DNR?

Why is it important to work within your scope or job description?

Have you any experience with a Hoyer lift or portable total body lift equipment?

Do you have experience with the Axxess software system?

List your previous employers beginning with the most recent employer.

Employer Name

Address

FROM

TO

Responsibilities

Job Title

Starting Hourly/ Final Hourly Pay

Supervisor Name/Phone

Reason for leaving

Employer name

FROM

TO

Job Title

Starting Hourly/ Final Hourly Pay

Responsibilities

Type a question

Employer Name

Address

FROM

TO

Responsibilities

Job Title

Starting Hourly/ Final Hourly Pay

Supervisor Name/Phone

Reason for leaving

Address

FROM

TO

Responsibilities

Job Title

Starting Hourly/ Final Hourly Pay

References: List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please)

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one 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 misrepresentation of facts called for 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 consumers reporting bureaus, to verify any 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 understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is

prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs before and during employment. Opulent Home Care is an equal opportunity employer. We strive to promote equality and diversity within the Agency, and this policy applies to all our employees, job candidates, volunteers, and contractors as well. Being an equal opportunity employer means we do not discriminate in employment on basis of nationality, color, sex, age, disability, religion, sexual orientation, and any other means as protected by all applicable state and federal laws.

Applicant's Signature

EMPLOYMENT APPLICATION

EMPLOYMENT BACKGROUND