IN TOUCH HOME CARE SOLUTIONS
Employment Application - DSP / Personal Assistant
APPLICANT INFORMATION
Full Name:
Address:
City/State/Zip:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Are you at least 18 years old?
Yes
No
Do you have reliable transportation?
Yes
No
Yes
No
License #:
State:
Authorized to work in the U.S.?
Yes
No
Have you ever been excluded from Medicaid/Medicare?
Yes
No
Have you ever been convicted of a felony or misdemeanor (excluding minor traffic)?
Yes
No
If yes, please explain:
POSITION AVAILABILITY
Position Applying For:
DSP
Personal Assistant
Employment Type:
Full-Time
Part-Time
PRN
On-Call
Days Available:
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Shift Preference:
1st
2nd
3rd
Overnight
Flexible
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EDUCATION
High School:
Diploma/GED?
Yes
No
College/Technical School:
Certifications (CPR, First Aid, CNA, etc.):
EMPLOYMENT HISTORY (Most Recent First)
Employer:
Address:
Supervisor:
Phone:
Format: (000) 000-0000.
Position:
Start Date:
-
Month
-
Day
Year
Date
End Date:
-
Month
-
Day
Year
Date
Reason for Leaving:
May we contact this employer?
Yes
No
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EQUAL EMPLOYMENT OPPORTUNITY STATEMENT
In Touch Home Care Solutions is an Equal Opportunity Employer. We do not discriminate based on race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other protected classification under federal, state, or local law.
AT-WILL EMPLOYMENT (Indiana)
If hired, employment is at-will. Either the employee or the Company may terminate employment at any time, with or without cause or notice, consistent with Indiana law.
Applicant Initials:
BACKGROUND CHECK AUTHORIZATION (FCRA)
I authorize In Touch Home Care Solutions to obtain consumer and/or investigative reports, including criminal history and driving record, in accordance with the Fair Credit Reporting Act and Indiana regulations.
Signature:
Date:
-
Month
-
Day
Year
Date
DRUG-FREE WORKPLACE ACKNOWLEDGMENT
I understand the Company maintains a drug-free workplace and agree to comply with all related policies.
Applicant Initials:
CONFIDENTIALITY & HIPAA ACKNOWLEDGMENT
I understand I may have access to confidential client information protected by HIPAA and Indiana waiver regulations. I agree to maintain strict confidentiality.
Applicant Initials:
APPLICANT CERTIFICATION
I certify that the information provided in this application is true and complete. I understand falsification may result in disqualification or termination.
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Applicant Signature:
Date:
-
Month
-
Day
Year
Date
Preview PDF
Submit
Submit
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