Caregiver Job Application Form

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Full Name*

First NameMiddle NameLast Name
ANY ALIASES OR MAIDEN NAMES USED PREVIOSLYIF NONE WRITE NONE*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Birth Date*

MonthDayYear
Are You a U.S. Citizen?*

YesNo
Do You Own A Car?*

YesNo
Do You Have A Drivers License?*

YesNo
Distance Willing To Travel?*
What Languages Do You Speak?

Skills/Qualifications:
Skills*
List any relevant skills
Qualifications*
List any relevant certifications or qualifications

Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Salary
Start Date

MonthDayYear
May We Contact?

YesNo
Previous Employment:
Previous Employer*
Name of Previous Employer
Position*
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
Previous Employer
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear

References:
Reference 1*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email
Reference 2*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email
Reference 3
Name of Reference
Relationship
Years Acquainted
Phone
Email

Cover Letter & Resume:
Cover Letter

Upload a File

Cancelof
Resume

Upload a File

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Send Application:
Pre-Employment Background Check Policy
To ensure a safe and secure workplace, Hope Heals requires all prospective employees to undergo a comprehensive background check as part of the hiring process. An authorization form will be provided and authorization required before proceeding. This background
check will include, but is not limited to:

1.Criminal History Check – A review of any past criminal convictions, including but not limited to felonies and misdemeanors.

2.Sex Offender Registry Check – Verification of any listing in national and state sex offender registries.

3.Abuse Offender Check – Screening for any history of abuse-related offenses, where applicable by law.

4.Driving Record Check – For positions that involve driving responsibilities, a review of the candidate’s motor vehicle records (MVR) will be conducted to assess driving history and eligibility.
5.Fraud- All names will be checked against the Attorney Generals OIG website.

6.Exclusion for Medicaid or Medicare – All names will be checked against the Excluded Parties List System website.

7.Payment Exclusion – All names will be checked against the DHHS Excluded Parties List System website.

Employment offers are contingent upon the successful completion of the background check process. Any findings will be reviewed on a case-by-case basis, considering the nature and relevance of the offense to the position being applied for. Failure to pass the background check may result in the withdrawal of the job offer.

Hope Heals complies with all federal, state, and local laws regarding background checks and will ensure that all information is handled confidentially and fairly.
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed by one of our affiliates, my employement may be terminated at any time.

In consideration of my employment, I agree to conform to the hired company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
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Employment Desired:

Education:

Skills/Qualifications:

Current Employment:

Previous Employment:

References:

Cover Letter & Resume:

Send Application: