NEO Home Care Employment Application

Welcome!

Thank you for applying to become one of Northeast Ohio Home Cares valued Team Members. We are very careful that we hire only the best and that each of our new Team Members participate in a very meaningful orientation program. Please be aware that a $115 onboarding fee will be charged to any employee who leaves employment before the end of 90 days.

We consider applicants without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

Which one of our locations are you applying to*

Position(s) Applied For*

Date of Application

Date

How did you learn about us?*

Name*

First NameMiddle NameLast Name

Address and Street

City

State

Zip Code

Phone*

Telephone Number

Area CodeNumber

Email Address

example@example.com

Social Security Number*

Best time to contact you at home:

:HourMinutesAM/PM Option

Are you fully vaccinated against COVID-19?*

YesNo

Which vaccine did you receive (Pfizer, Moderna, etc.)?

If you are under 18 years of age, can you provide proof of your eligibility to work?

YesNoN/A

Have you ever filed an application with us before? If Yes, give approximate date:

NoOther

Have you ever been employed with us before? If Yes, give date*

NoOther

Do any of your friends or relatives, other your than spouse, work here? If Yes, please list them*

NoOther

Are you currently employed?

YesNo

May we contact your present employer?

YesNo

Have you ever been convicted of a crime?*

YesNo

Please detail convictions:

	Date of Conviction	Nature of Conviction	Jurisdiction
1
2
3

Do you understand that proof of citizenship or immigration status will be required upon employment?*

YesNo

Date available for work

Date

What is your desired salary range?

Availability:

Full TimePart TimeOther

Which shift(s) if applicable?

FirstSecondThirdN/A

Are you currently on “lay-off” status and subject to recall?

YesNo

Can you travel if a job requires it?

YesNo

State any additional information you feel may be helpful to us in considering your application, including any job related training in the U.S. Military.

Education

	Name and Address of School	Course of Study	# of Years Completed	Diploma/Degree
High School
Undergraduate College
Graduate/Professional
Other (Specify)

Your social security number and birth date will be required if we need to conduct a background check and for tax purposes if you are hired.

Employment Experience: Start with your present or last job. Include any job-related military service assignments and volunteer activities. How many job experiences would you like to add (maximum of 3):

Employment Experience 1

	_______________________________________________________
Employer Name
Address
Phone Number
Starting/Present Job Title
Supervisor Name
Reason For Leaving
Dates Employed (from/to)
Work Performed
Hourly Rate/Salary (starting and ending)

Can we contact this employer?

YesNo

Employment Experience 2

	_______________________________________________________
Employer Name
Address
Phone Number
Starting/Present Job Title
Supervisor Name
Reason For Leaving
Dates Employed (from/to)
Work Performed
Hourly Rate/Salary (starting and ending)

Can we contact this employer?

YesNo

Employment Experience 3

	_______________________________________________________
Employer Name
Address
Phone Number
Starting/Present Job Title
Supervisor Name
Reason For Leaving
Dates Employed (from/to)
Work Performed
Hourly Rate/Salary (starting and ending)

Can we contact this employer?

YesNo

Please include references that have knowledge of your professional work experience and at least one former supervisor.*

	Name	Phone	Best Time To Call	Occupation	Fax	Email
Reference 1
Reference 2
Reference 3

I hereby certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I give permission to follow up on my references. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment after this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. 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 Employer. I agree that any claim or lawsuit relating to my service with this organization or any of its subsidiaries must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary. If I am hired, this application shall become part of my employment record.*

Please sign your name using your mouse or finger, depending on which device you're using

Date

Consent to Pre-Employment Drug Testing

Northeast Ohio Home Care is a drug-free workplace. All applicants are required to complete a drug screen prior to employment.

I understand that submission to a pre-employment drug screen is a condition of employment with Northeast Ohio Home Care, "Network". I understand that should my test results be confirmed positive or I refuse a test, I will not be eligible for employment.

I hereby give my consent to release the results of my specimen to the specified agent for the purpose of determining the presence of drugs and/or alcohol in my body.

By signing this form, I hereby release to the Network the results of the test(s) to which I have consented. I further authorize the Network to discuss the results with the testing provider and authorized representatives as needed.

A Parent or Guardian may sign if applicant is a minor

Do you consent to a pre-employment drug screening?*

YesNo

Signature

Please sign your name using your mouse or finger, depending on which device you're using

Name

Date

I hereby refuse to consent to submit testing for the presence of drugs and/or alcohol.

A Parent or Guardian may sign if applicant is a minor

Signature

Please sign your name using your mouse or finger, depending on which device you're using

Name

Date

TB Test Consent for Minor Applicants Only

Are you a minor?

NoYes

Minor's First and Last Name

Minor Signature

Please sign your name using your mouse or finger, depending on which device you're using

Date

Parent or Legal Guardian Signature

Please sign your name using your mouse or finger, depending on which device you're using

Date

Why Do I Have to Get Fingerprinted?

When you apply for a job with Northeast Ohio Home Care, state law requires that you get fingerprinted. State law states that all people who work with the elderly have to be checked to see if they have a criminal record. This is true even if you don't have a record. The law was passed to protect elderly people (and people who work with them) from convicted criminals. We apologize for any inconvenience and appreciate your interest in working for Northeast Ohio Home Care.

Background Checks Policy

When completing your application please note Northeast Ohio Home Care' Background Checks policy:

Should the background investigation(s) disclose any material discrepancies, misrepresentation or omission on the application form or disclose information indicating that the individual is not suited for hire; the applicant shall not be employed, or, if already employed, shall be immediately terminated.

Long-term Care Background Check and Home & Community-Based Services Background Check and Attestation Form

By signing this form, I consent to the submission of a request for a criminal records check (including database reviews) for long-term care and community-based service workers, as required by the Ohio Revised and Administrative Codes.

This request will be submitted by Northeast Ohio Home Care to the Bureau of Criminal Investigation prior to employment and every five years if applicable and as determined by my employment status and location of employment.

I also attest to the following:

1. That I have not been convicted or plead guilty to any of the crimes that would disqualify me from working with older adults under Ohio Administrative Code 3701-13-05 and 3701-60-06.

2. That I understand and agree that if I am found to have a record of any of those crimes, or if Northeast Ohio Home Care does not receive a response from BCI/FBI within 30 days, I will not be hired for work with older adults or, if I have already been hired, that my conditional employment will be terminated.

3. That I was informed that I must provide a set of fingerprint impressions and that a criminal records check must be conducted if I come under final consideration for employment.

4. I have resided in Ohio for the past five years. I understand that if I have not resided in Ohio for the past five years an FBI background check will also be conducted:

YesNo

Applicant Signature (Parent or Guardian Signature if applicant is a minor)

Please sign your name using your mouse or finger, depending on which device you're using

Applicant Name

Date

Professional Reference Check Form

Northeast Ohio Home Care may contact your former employer(s) and/or personal references and request information such as

Dates of employment
Positions held
Reason for separation
Rehire eligibility
Any additional relevant information

I hereby authorize the release of any and all information concerning my employment, conduct, and abilities to Northeast Ohio Home Care.

Please sign your name using your mouse or finger, depending on which device you're using

Name

Date

Social Security Number*

Voluntary Self-Identification Form

Northeast Ohio Home Care is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite employees to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may be used only in accordance with the provisions of applicable laws, Executive Orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Do you wish to voluntarily self-identify?

YesNo

Name

First NameLast Name

Signature

Please sign your name using your mouse or finger, depending on which device you're using

Gender

MaleFemale

Marital Status

SingleMarried

Do you have children?

YesNo

Race/Ethnicity

White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.