Application for Employment

Application for Employment
This application must be completed in full for consideration. Applications are kept on file during time employed with Destination Healthcare Services. Please print clearly and check boxes or circle Yes or Now here applicable.*

YesNo
Date of Birth*

MonthDayYear
Date
Date of Application*

MonthDayYear
Date
PERSONAL
Name:*

First NameMiddle NameLast Name
Social Security No.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone: Home*
Please enter a valid phone number.
Cell*
Please enter a valid phone number.
Other*
Please enter a valid phone number.

EMPLOYMENT HISTORY

List your last three (3) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain gaps in employment in comments section on next page.
Employer*
City, State*
Telephone*
Please enter a valid phone number.
Job Title*
Job Description*
Reason for leaving*
Employment Dates
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Starting Wage*
Final Wage*
May we contact?*

YesNoLater
Employer*
City, State*
Telephone*
Please enter a valid phone number.
Job Title*
Job Description*
Reason for leaving*
Employment Dates
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Starting Wage*
Final Wage*
May we contact?*

YesNoLater
Employer*
City, State*
Telephone*
Please enter a valid phone number.
Job Title*
Job Description*
Reason for leaving*
Employment Dates
From*

MonthDayYear
Date
To*

MonthDayYear
Date
Starting Wage*
Final Wage*
May we contact?*

YesNoLater
Comments (including explanation of any gaps in employment)*

EDUCATIONAL BACKGROUND

List Schools attended:*

	Degree/Diploma	Major/Minor
High School or Equivalent
College

PROFESSIONAL CERTIFICATIONS

Please provide copies of any certifications when you submit your application.

Certification*

	Expiration Date	Had But Not Current
Adult CPR
First Aid
Medication Administration for Unlicensed
Personnel
CNA, RN, LPN (Circle One)
Other

Have your professional license or clinical privileges ever been revoked, suspended, reduced, limited, voluntarily surrendered or not renewed in this or any other state?*

YesNo
Do you have any malpractice claims ever resulted in a settlement against you?*

YesNo
Have you been involved in a DIDS investigation prior to this application?*

YesNo
If “Yes” to any of the above, please explain:*

ADDITIONAL INFORMATION
List any additional information you would like us to consider, including skills and qualifications acquired from employment or other experiences that may qualify you for work with our company: (Exclude information, which would reveal sex, race, religion, national origin, age, ancestry, disability, or other protected status information)*
PERSONAL REFERENCES
List name and telephone number of three (3) personal references that are not related to you. NOTE: At least one of the personal references you list must have known you for at least 5 years.

	Personal Reference (NO FAMILY)	Relationship to Reference (NO FAMILY)	Years Known	Phone Number
1
2
3
4
5

EMPLOYEE RELEASE AND PRIVACY STATEMENT
I understand that the company requires certain information about me to evaluate my qualifications for employment and to conduct its business if I become employed. Therefore, I authorize the company to investigate my past employment, educational credentials and other employment related activities.

I agree to cooperate in such investigations and release those parties supplying such information to the company from all liability or responsibility with respect to information supplied.

I understand that any false answers or statements, including the failure to give a complete disclosure of facts as requested on this application or any supplement thereto or in connection with the above mentioned investigations, will be sufficient grounds for failure to hire, or immediate termination of employment.

I agree that the company may use the information it obtains concerning me in the conduct of its business.

I understand that such use may include disclosure outside the company in those cases where its agents and contractors need such information to perform their function, where the company legal interests and/or obligations are involved, or where there is a medical emergency involving me.

I hereby release the company for any liability and agree to hold harmless any officer, director, agent or employee of the company who furnishes such information. I understand that after a conditional offer of employment, I may be subject to satisfactorily passing a including a medical scan for illegal and/or non-prescription drugs by a health care provider designated by the company.

I further agree to submit myself for random, or for cause, drug screens as required by the company. If I am employed, and at any time suffer personal injuries for which I shall make a claim, I hereby agree to submit myself to examination by a doctor selected by the company and as often as deemed necessary and requested. Any failure on my part to comply with this request shall result in my claim being considered waived and any legal action abated.

I further agree that in case of injury, where insurance is carried under an employer’s compensation law, to waive all actions for damages and accept said insurance.

I understand that employment is “at will”. Employment is not for a fixed time and may be discontinued, with or without notice or cause, by myself or the company.

I understand that no employee, officer, representative or publication may obligate the company to anything contrary to the above. I, the undersigned applicant, certify and affirm that, to the best of my knowledge and belief;

I [“have” or “have not,” as applicable] had a case of abuse, neglect, mistreatment or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation, I further release and authorize Destination Healthcare Services, LLC, the Tennessee Department of Intellectual and Developmental Disabilities and the Bureau of TennCare to have full and complete access to any and all current or prior personnel or investigative records, from any party, person, business, entity or agency, whether governmental or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment or exploitation and to consider this information as may be deemed appropriate. This authorization extends to providing any applicable information in personnel or investigative reports concerning my employment with this employer to my future employers who may be Providers of DIDD services.
Applicant’s Signature:*

Clear
Date*

MonthDayYear
Date
It is our policy to provide employment, training, compensation, promotion and other conditions of employment based on qualifications, without regard to race, religion, national origin, sex, sexual orientation, age, veteran status or disability. EOE

DESTINATION HEALTHCARE SERVICES
I recognize that any offer of employment to me by Destination Healthcare Services, Inc. is conditional upon my successfully passing reference and background screenings. I understand that Destination Healthcare Services, Inc. shall conduct Pre-Employment Reference and Background Checks thoroughly and within the confines of all applicable state and federal laws. In consideration of review of my application for employment, I hereby release any individual, entity, and from all claims or liabilities that might arise from the inquiry into or disclosure of such information, including claims under any federal, state, or local civil rights law and any claims for defamation or invasion of privacy.

I hereby voluntarily consent to and authorize Destination Healthcare Services, Inc. or its authorized representative bearing this release or copy thereof, in connection with my application for employment with Destination Healthcare Services, Inc., to obtain a consumer report (no credit check will be performed) for employment purposes including:

Criminal History
Department of Motor Vehicle History Certification
Licensing Educational Credentials
Employment Eligibility (Social Security Number Check)
Employment Checks
Reference Checks

Reference Checks I authorize all persons who may have information relevant to this research to disclose such information to
Destination Healthcare Services, Inc., or its agents, and I hereby release all persons from liability on account of true and accurate disclosure. I hereby further authorize that a photocopy of this authorization be considered as valid as the original. Should there be any questions as to the validity of this release, you may contact me as indicated below.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Printed Name (Last, First, MI, (Maiden Name)*
Driver’s License and Issuing State*
Expiration Date*

MonthDayYear
Date
Telephone Number*
MobileHome
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

APPLICANT REFERENCE CHECK CONSENT FORM
To:*
Fax:*
From: Human Resources Department Destination Healthcare Services

Return to: Humanresources@destinationhcs.com
Date*

MonthDayYear
Date
Applicant Name:*
SSN:*
The applicant listed above is being considered for employment by Destination Healthcare Services and has listed your organization as a current or former employer. Please complete the form below and fax back to our office at the above indicated number

APPLICANT’S AUTHORIZATION
I voluntarily consent to authorize Destination Healthcare Services or any of its officers, employees, or agents to check my references by contacting any person or entity whom they deem to be an appropriate reference. I understand that questions may be asked about my educational background, work experience, achievements, wage history, performance, attendance, personal history, character, personality, disciplinary information and reason for separation from former employment.

It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment with Destination Healthcare Services.

I also hereby release Destination Healthcare Services from all liability for damages or claims – including, but not limited to, defamation, interference with contract, and negligence – which may arise or result from any reference information gathered pursuant to this authorization.
Applicant’s Signature:*

Clear
Date:*

MonthDayYear
Date
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Application for Employment

PERSONAL

POSITION

MINIMUM EMPLOYMENT REQUIREMENTS

EMPLOYMENT HISTORY

EDUCATIONAL BACKGROUND

PROFESSIONAL CERTIFICATIONS

ADDITIONAL INFORMATION

PERSONAL REFERENCES

EMPLOYEE RELEASE AND PRIVACY STATEMENT

DESTINATION HEALTHCARE SERVICES

APPLICANT REFERENCE CHECK CONSENT FORM

APPLICANT’S AUTHORIZATION

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