EMPLOYMENT APPLICATION
Note: Applications will not be processed unless this application is fully completed
Full Name
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First Name
Middle Name
Last Name
Birthdate
*
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Month
-
Day
Year
Date
Social Security Number
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
You are at least 18 years of age?
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Please Select
YES
NO
You are able to meet the physical and mental demands required to perform specific tasks for the consumer?
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Please Select
YES
NO
You agree to maintain confidentiality?
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Please Select
YES
NO
You are emotionally mature and dependable?
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Please Select
YES
NO
Are you able to handle emergency situations?
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Please Select
YES
NO
Are you consumer's spouse?
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Please Select
YES
NO
Have you lived in Missouri for the past 5 years?
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Please Select
YES
NO
If No, please list the state you lived in.
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Do you smoke?
*
Please Select
YES
NO
How did you learn of this position?
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Is there any reason why you would not be able to perform the job duties?*
*
Please Select
YES
NO
Yes, please explain below:
*
BACKGROUND HISTORY
Background History If you are hired for the position of Personal Care Attendant (PCA), a background screening via the Family Care Safety Registry (FCSR) must be conducted prior to your first day of employment. Please read the following questions carefully and respond truthfully and fully. BACKGROUND CHECK FEE $15.25
Please disclose all criminal convictions, findings of guilt, pleas of guilt, and pleas of nolo contendere or provide a statement that there is no record of such background. Failure to disclose any criminal information is a violation of the law. If this does not apply please use N/A.
Have you been charged with an offense other than a minor traffic violation?
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Please Select
YES
NO
If Yes, Give Offense and Date for Each Crime:
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I give ABUNDANT CHOICE HHS, LLC consent to conduct a pre-employment criminal record check.*
*
Please Select
YES
NO
If No, please explain:
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I authorize ABUNDANT CHOICE HHS, LLC to conduct a closed record check pursuant to Section 610.120, RSMo
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Please Select
YES
NO
If No, please explain:
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Have you ever used any aliases and social security numbers other than the name and social security number you used on this application?*
*
Please Select
YES
NO
If YES, please disclose all aliases and social security numbers that you have used:
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Are you registered with the Family Care Safety Registry?*
*
Please Select
YES
NO
Have you applied for a Good Cause Waiver?*
*
Please Select
YES
NO
Do you have a Skilled License?*
*
Please Select
YES
NO
If YES, what type?
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Do you have a valid Driver's License?*
*
Please Select
YES
NO
Do you have transportation?*
*
Please Select
YES
NO
Have you ever worked with persons with physical/cognitive disabilities?*
*
Please Select
YES
NO
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Preferences and Availability:
Which do you prefer working with?
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Male
Female
Both
Please check the following duties that you are willing and able to perform on a daily basis
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Dressing
Feeding
Errands
Laundry
Transfers
Shopping
Showering
Toilet Routine
Homework
Cleaning
Meal Preparation
Correspondence
Other
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Availability
*
Morning
Evening
Night
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
EMPLOYMENT
*
COMPANY
SUPERVISOR
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PHONE NUMBER
EMAIL
Employment Start Date
*
-
Month
-
Day
Year
Employment End Date
*
-
Month
-
Day
Year
Are you available for re-hire?
*
Please Select
YES
NO
May we contact this employer?
*
Please Select
YES
NO
Responsibilities
*
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Reason for leaving
*
Reference Check
Please use this section to provide a professional reference.
Reference
*
FULL NAME
RELATIONSHIP
*
PHONE NUMBER
COMPANY
Job Position that your applying for?
*
Client's Name that you will work for?
*
Did someone refer you? Let us know their name below.
*
I certify that all of the information contained in this application is true and complete and I authorize verification of any or all information presented above.
First Name
Middle Name
Last Name
ID Upload
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Signature
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ABUNDANT CHOICE HOME HEALTHCARE SERIVICES, LLC is an equal opportunity employer. In accordance with the Civil Rights Act of 1964, our agency does not discriminate in employment due to race, creed, religion, age, national origin or disability.
Please verify that you are human
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