DHSCS DIAGNOSTIC LABS LLC

866-757-LABS(5227) (office) 804-404-9532 (fax) info@dhscsdalabs.com www.dhscsdklabs.com

Date Applied: Position Applying For:

Type a question

Date Applied*

Date

First Name*

Middle Name*

Last Name*

Apt/Suite*

City*

Street*

State*

Zip*

Home*

Cell*

Email Address*

example@example.com

SSN*

Month*

Day*

Year*

Male*

Female*

other*

What languages do you speak? Preferred Language?

What languages do you speak?*

Relationship type: Phone Number to contact in the event of an emergency: Full Name:

Full Name*

Preferred Language?*

Contact #1*

Relationship type*

Relationship type: Phone Number to contact in the event of an emergency*

Degree*

Certificate*

Do you have current First Aid Certification? Do you have current CPR Certification? COVID Vaccinated? Yesno 40 hour caregiver certification:

Do you have current First Aid Certification?*

Expiry Date*

Date

Do you have current CPR Certification?*

Expiry Date*

Date

certification*

File Upload

COVID-19 Questionnaire: Have you been vaccinated (not required for employment)? Yes or No (attach form)

866-757-LABS(5227) (office) 804-404-9532 (fax) info@dhscsdxlabs.com www.dhscsdxlabs.com

If no, COVID-19 test required once a WEEKLY or as needed to ensure client and employee

workplace safety. (COVID-19 Testing site resources will be provided at Orientation)

Part time*

Indicate Days and List Hours Available for Work:

From*

To*

[Tuesday: Wednesday: Thursday: Friday: [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?

Yes or No (circle) List any work limitations that you may have and briefly describe:

**Attach resume** *Attach Certificate** *attach Recommendation Letter**

What locations are you willing/able to work? select all that apply) Virginia BeachChesapeake Newport NewsWilliamsburg

Eastern Shore (Northampton Co)

Transportation Transportation Walver form)

Do you have reliable transportation? Do you have adequate vehicle insurance? Are you willing to drive a client's vehicle?

Do you have a valid Driver's License or Identification Card?

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

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

866-757-LABS(5227) (office) 804-404-9532 (fax) info@dhscsdxlabs.com

Company Name*

Physical Address*

Supervisor's Name*

Position Held*

Length of Employment*

Reason for Leaving*

Full Name*

Physical Address*

Nature of Friendship (friend, co-worker, family etc, (Other than relative Length of Relationship:

Nature of Friendship (friend, co worker, family etc.), (Other than relative.)*

Length of Relationship*

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 DHSCS Diagnostic Labs LLC and hereby release and discharge any of the above and DHSCS Diagnostic Labs LLC and 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, random drug test and criminal background test, 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 in order to be considered for employment with DHSCS Diagnostic Labs LLC and background check must be completed random drug test for certain positions, may be conditional upon successful completion of a substance abuse screening test and an criminal background check.

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

Applicant's Signature*

Date*

Date

866-757-LABS(5227) (office) 804-404-9532 (fax) info@dhscsdxlabs.com www.dhscsdxlabs.com

Employer comment section Only:

Feedback on interview

Date of Hire

Date

Probation Period

Accepted Job Title

Full time or Part time

EMPLOYMENT APPLICATION

DHSCS

DHSCS