Employee Application

Application for Employment

All of the items below are required to complete your file for employment.
Here's an overview of the application process

Fill out the Application for Employment form completely, sign, date, and notarize where required. This form asks for the following:
- Resume
- Personal Information, including a copy of your:
  - Driver's License
  - Social Security Card
  - Proof of Residency, Citizenship, or Employment permit (whichever is applicable)
    
    Passport or voter registration (U.S. citizen)
    
    Residency or Green Card
    
    Authorized worked permit from immigration
  - Car Registration and Insurance
- Education (and a copy of diploma)
- Professional License/s or Certification/s
- Inservices
  - CPR & First Aid
  - HIPPA
  - HIV /AIDS
  - Bloodborne pathogens
  - APD Direct Core competencies, Zero Tolerance, all wavier provider course
  - Related disease trainings (Alzheimer’s, Cerebral Palsy, Dementia, Autism, etc.)
- Work Experience
- Two letters of recommendation
- Two references to be contacted (reference check via in-person or phone call).
- Good Moral Character Affidavit
- ACHA Background Screening
- Signed Zero Tolerance Policy, HIPPA Privacy Policies
- Direct Deposit Form & Voided Check
- Applicable Tax Form
- Application Acknowledgement (download the file, then upload signed, dated, and notarized document on the last page of this online application form) Application will NOT be considered complete without this document.
If you meet our criteria, we'll invite you for an interview and request additional documents, if any.
Position Applying For
Date*

MonthDayYear
Date

Personal Information
First & Last Name*
Middle Name
Social Security Number*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Resume*

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Driver's License*

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Social Security Card*

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Proof of Residency, Citizenship, or Employment Permit (whichever is applicable)*

Passport or voter registration (U.S. citizen), residency or Green Card, authorized work permit from immigration
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Car Registration & Insurance*

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Work Preferences
What shifts do you prefer to work?*

Education
Name of School or Institution*
Location of School or Institution*
Degree/Diploma Obtained*
Date Degree/Diploma Obtained*

MonthDayYear
Date
Diploma*

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Name of School or Institution
Location of School or Institution
Degree/Diploma Obtained
Date Degree/Diploma Obtained

MonthDayYear
Date
Diploma

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Special License & Certification
License/Certification Type
License/Certification Number
State where it was obtained
Expiration Date

MonthDayYear
Date
License/Certification Type
License/Certification Number
State where it was obtained
Expiration Date

MonthDayYear
Date

Inservices
- CPR & First Aid
- HIPPA
- HIV /AIDS
- Bloodborne pathogens
- APD Direct Core competencies, Zero Tolerance, all wavier provider course
- Related disease trainings (Alzheimer’s, Cerebral Palsy, Dementia, Autism, etc.)
Upload all available inservices documents

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Emergency Contact
Name*
Phone Number*
Please enter a valid phone number.
Address*
Relationship to applicant/employee*

General Information
Are you legally authorized to work in the United States?*

YesNo
Have you ever been convicted of a felony or misdemeanor crime?*

YesNo
(This does not apply if the conviction has been expunged, is contained in a sealed record, or was juvenile.)
If yes, state the basis for each conviction:

Work Experience

Please complete all appropriate items, even if you have provided us with a resume.
Company Name
Salary
Job Title
Job Description
Name of Supervisor
Supervisor's Phone Number
Please enter a valid phone number.
Can the supervisor be contacted?

YesNo
Company Address
Employment Date (from when to when)
Reason for leaving
Company Name
Salary
Job Title
Job Description
Name of Supervisor
Supervisor's Phone Number
Please enter a valid phone number.
Can the supervisor be contacted?

YesNo
Company Address
Employment Date (from when to when)
Reason for leaving

References & Letter of Recommendation

Please list at least two (2) individuals with whom you have worked with, who were in position to evaluate your performance.
Name*
Company*
Job Position*
Phone Number*
Please enter a valid phone number.
Name*
Company*
Job Position*
Phone Number*
Please enter a valid phone number.
Name
Company
Job Position
Phone Number
Please enter a valid phone number.
First Letter of Recommendation

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Second Letter of Recommendation

Cancelof
Signature
Full Name*
Date*

MonthDayYear
Date
Signature*

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Attestation of Good Moral Characters
By signing this form, I affirm and attest that I meet the Moral Character requirements for employment as required pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes.
Employee/Applicant/Contractor/Volunteer Name*
Provider/Employer Name*
I have not been arrested with disposition pending or found guilty of regardless of adjudication, or entered a plea of nolo contendre (no contest) to or have been adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under any of the folowing provisions of the Florida Statutes or under any similar statute of another jurisdiction for any of the offenses listed in the PDF Ffile attached below.
The following acknowledgements apply to all Direct Service Providers and/or Employees, Contract Providers, and Volunteers. Please add initials to each statement.
Initials*

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I affirm that I have not been designated a s a sexual predator pursuant to s. 775.21; a career offender pursuant to s. 775.261; or a sexual offender pursuant to s. 943.0435, unless the requirement to register as a sexual offender has been removed pursuant to s. 943.04354.
Initials*

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I understand that I must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any similar statute of another jurisdiction, regardless of whether or not those records have been sealed or expunged.
Initials*

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I understand that, while employed or volunteering in any position that requires an APD background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest, any notice of possible criminal prosecution including any violation or infraction mandating a court appearance. Reporting must be done immediately if during normal working hours or immediately the next business day if after normal working hours.
One of the following statements MUST be signed:
I attest that I have read the above carefully and state that my attestation here is true and correct and that my record does not contain any of the above listed offenses. I understand, under penalty of perjury, al employees in such positions of trust or responsibility shall attest to meeting the requirements to the background screening standards set forth ni Chapter 435 and Section 393.0655.
Signature of Affiant

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Date

MonthDayYear
Date
OR
My record contains one or more of the applicable disqualifying acts or offenses listed above.
Signature of Affiant

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Date

MonthDayYear
Date
Note: If you have previously been granted an APD exemption for this disqualifying offense, a copy of the APD exemption letter must be attached.

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OR
I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be holding a position that is within the scope of my licensed practice, and I am not subject to the screening provisions of section 393.0655, Florida Statutes.
Signature of Affiant

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Date

MonthDayYear
Date

Zero Tolerance Policy
a. Penalties for Sexual Abuse: Confirmed cases of sexual abuse by service providers will result ni immediate termination of the waiver enrollment status of the individual who committed the abuse as wel as the imposition of legal penalties. If ti si determined that administrators, Owners, or operators of a provider agency are considered to be culpable form the abuse through negligence or failure ot report the incidents), their waiver enrollment statue wil be terminated. Criminal and administrative penalties will be pursued.

b. Mandatory Reporting Requirements: Apersonwithknowledgeoforhavingreasonable cause ot suspect that a child si being sexually abuse by a parent, legal custodian, caregiver, or other person responsible for the child's welfare, as defined ni Section 39.201.F.S. si required to report such knowledge or suspicion ot the Department's Central Abuse Hotline at 1-800-96-ABUSE (1-800-962-2873).

Pursuant to Section 415.1034, FS, any service provider with knowledge of, or having reasonable cause to suspect that a vulnerable adult has been or is being abused, neglected or exploited shall immediately report such knowledge or suspicion ot the Department's Central Abuse Hotline at -1 800-96-ABUSE (1-800-962-2873).

Failure to report known or suspected cases of sexual abuse represents an offense that will be cause for termination of waiver enrollment status. Criminal and administrative penalties wil be pursued.

c. Client-on-Client Sexual Abuse: Known or suspected sexual abuse between two individuals with developmental disabilities must also be reported immediately to the Central Abuse Hotline at 1-800-96-ABUSE (1-800-962-2873), so that an investigation wil occur ni order to determine whether or not the sexual abuse was the result of inadequate supervision or neglect on the part of a service provider or caregiver. The incident must also be reported immediately ot the District or Regional Developmental Disabilities Program Office ot ensure the continued health and safety of the individuals involved.
Signature*

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Date*

MonthDayYear
Date

HIPPA Privacy Policies
Essential Wellness of South Florida, Inc. have the folowing abides by the HIPPA laws of privacy and confidentiality for our clients as wel as for our employees. Al employees wil receive training on our HIPPA policies upon hiring and an updated training wil be given yearly. If any policy si added, the training shall be immediately. Essential Wellness of South Florida, Inc. understands hte right of our clients and employees for dignity, respect, and confidentiality.

At no time under any circumstances shall any information, medical, personal or of any nature, about our clients or employees shall be given ot anyone without by any person other than the administration. The Essential Welness of South Florida, Inc. administration wil only give information fi there si a proper consent form signed by the client, guardian and employee. The consents for release of information will only be valid for a year. Your company reserves the right to withhold any information from being released fi ti finds ti necessary ot consult again with the client, guardian, family member or employee.

The full names of our clients and employees shall not be displayed ni the open at any time. The last name and first name initial shall be the only way displayed.

At no time shall any employee give information of where the clients are. Al questions pertaining to clients shall be referred immediately to the administration.

No employment information regarding our employees will be given over the phone. The interested party must send a fax with a release of information signed by the employee. The required information wil be sent back to the interested party via fax.

All personal and medical information of the clients as well as of the employees shall be kept ni a locked cabin and the administration shall hold the key.

Any employee who knowingly or otherwise violates this policy wil eb terminated immediately.
Signature*

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Date*

MonthDayYear
Date

Direct Deposit Slip
Name
Branch
Complete the required information. Alow at least 2-3 weeks for processing. For checking accounts, a copy of a voided check must be provided. For savings accounts, a copy of a deposit slip must be provided.
Name of Bank
Routing #
Account #
CHECKING SAVINGS
I would like to deposit: Entire Net Pay, bi-weekly into my bank account
Attach a copy of voided check/savings deposit slip

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I order for this direct deposit authorization to be valid, the name of the employee must be on the voided check or deposit slip. A notice from the bank authorizing the employee to deposit funds into the account wil be accepted.

Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.
1. Name as shown on your income tax return Name is required on this line; do not leave this line blank.*
2. Business name/disregarded entity name, if different from above
3. Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/estateLimited liability company.Other
If you selected "Limited liability company", enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
4. Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
5. Address

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
Requester's name

First NameLast Name
Requester's address

Number, Street, and Apt. or Suite No.

Street Address Line 2

CityState

Zip Code
List account number(s) here (optional)
Part I - Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Social security number
X
X
X
-
X
X
-
X
X
X
X
Employer identification number
X
X
-
X
X
X
X
X
X
X
Part II - Certification
Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Signature

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Date

MonthDayYear
Date
You can check out the details and general instructions below:

Application Acknowledgement
DO NOT submit your application WITHOUT the signed, dated, and notarized copy of this Application Acknowledgement form.

Application will NOT be considered complete without this document.
1. Download this Application Acknowledgement form.
2. Upload signed, dated, and notarized copy below.
Required*

Cancelof
Should be Empty:

Application for Employment

Here's an overview of the application process

Personal Information

Work Preferences

Education

Special License & Certification

Inservices

Emergency Contact

General Information

Work Experience

References & Letter of Recommendation

Signature

Attestation of Good Moral Characters

One of the following statements MUST be signed:

Zero Tolerance Policy

HIPPA Privacy Policies

Direct Deposit Slip

Request for Taxpayer Identification Number and Certification

Part I - Taxpayer Identification Number (TIN)

Social security number

Employer identification number

Part II - Certification

Application Acknowledgement