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Date*

Todays Date

Email*

example@example.com

Name*

First NameLast Name

Date of Birth*

Social Security Number

Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

Have you resided in the state of Missouri for 5 years or more?*

YesNo

If no, please list all the previous states you have resided in, along with corresponding dates.

If you have resided in another state, a nationwide criminal background check will be completed including open and closed records.

Position applying for:*

Are you 18 years of age?*

YesNo

Can you legally work in the United States?*

YesNo

Please provide a copy of your current driver's license/State ID and social security card.*

Have you ever been convicted of, or pleaded guilty to, found guilty of, and/or nolo contendere to a felony or misdemeanor, except a minor traffic violation?*

YesNo

A closed record check will be completed. If yes, please explain.

Have you ever been charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of charges?*

YesNo

If yes, please explain.

Have you ever been discharged(fired, laid off, etc) from a job?*

YesNo

If yes, please explain.

Have you ever had any professional or occupational license or certification suspended/revoked?*

YesNo

If yes, please explain.

Are you able to meet the attendance requirements of this job?*

YesNo

Are you able to perform the functions of this job, as listed on the job description?*

YesNo

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?*

YesNo

Have you ever used an alias (first and/or last name) or social security number other than the one used to apply for employment with CUNNINGHAM'S IN-HOME HEALTH SERVICES, LLC? (Please list below: include maiden name, any/all married names used, and/all social security numbers used)*

Do you consent to a pre-employment background/criminal record check (including all open and closed records)?*

YesNo

Are you a registered worker on the Family Care Safety Registry in the State of Missouri?*

YesNo

If yes, under what name and Social Security Number?

Have you ever been listed on the Employee Disqualification List in the State of Missouri and/or applied for Good Cause Waiver?*

YesNo

If yes, under what name and social security number?

Please explain the circumstances and current status:*

Education*

	Graduation Year	Years Attended	Graduation Year	Subjects Studied	Diploma, Degree/Certifications
1
2
3
4

Please list any additional skills or training you may have related to the position you have applied for:

Professional license(s), certification(s):*

	License/ Certfication Number	Expiration Date	State	Status
1
2
3

Have you ever been disciplined, suspended or terminated from employment due to abuse, neglect or exploitation of a resident/patient/client?*

YesNo

If yes, please explain.

Date you are available to start?*

Salary Desired*

Are you currently employed?*

YesNo

If so, may we inquire for your present employer?*

YesNo

Have you ever applied to this company before?*

YesNo

Availability*

Full TimePart TimeAs Needed

Days Available*

Describe times availability (for example - 7:00am-7:00pm M,W, F and Saturday)*

Work Experience

Please list your employment history for the past 5 years, starting with the most recent job. *

	Employer	Address	Phone	Position	Dates	Salary	Job Duties	Reason for leaving
1
2
3
4
5

May we contact your employer for references/verification purposes?*

YesNo

APPLICANT'S STATEMENT OF UNDERSTANDING AND SIGNATURE:

False information provided or implied on an application or material omission is grounds for immediate dismissal without further notice.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that omission, false, or misleading information in my application and/or interview may result in my discharge/termination of employment.

I understand and authorize CUNNINGHAM'S IN-HOME HEALTH SERVICES, LLC to obtain a criminal background check, closed record check, and EDL background check through the FCSR, and FBI background check if applicable. CUNNINGHAM'S IN-HOME HEALTH SERVICES, LLC may contact my former employer in connection with the consideration of my employment. All references are hereby authorized to release all information which may be relevant to my employment and experience.I hereby release CUNNINGHAM'S IN-HOME HEALTH SERVICES, LLC, its employees, affiliates and successors from any liability that may arise due to information provided by references.

I understand that I am required to provided proof of identity and legal authorization to work in the United States and the Federal Immigration laws require me to complete an 1-9 form in this regard, as well as provide any necessary documentation.

I understand that this application remains current for only 60 days. At the conclusion of that time, if I have not heard from CUNNINGHAM'S IN-HOME HEALTH SERVICES, LLC and still wish to be considered for employment, it will be necessary for me to reapply and complete a new application.

This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of CUNNINGHAM'S IN-HOME HEALTH SERVICES, LLC is authorized to make any assurances to the contrary and that no other agreement(s) are valid unless they are in writing and signed by the owner/director.

I agree that if hired, I will follow all state rules and regulations, company policies, rules, procedures and all other directives pertaining to my employment (I understand CUNNINGHAM'S IN-HOME HEALTH SERVICES, LLC reserves the right to add, change, and/or delete any policies, procedures, work rules and/or benefits at any time).

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENTS.

I certify that I have read, fully understand, and accept all terms of the foregoing applicant's statement of understanding and authorization.

Terms and Conditions*

Signature

Date*

Date

Please verify that you are human*

Cunningham’s In-home Health Services

Employment Desired:

Work Experience

APPLICANT'S STATEMENT OF UNDERSTANDING AND SIGNATURE: