• We do not discriminate on the basis of age over 40, race, sex, color, religion, national origin, disability, or any other applicable status protected by state and local law. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job related factors.

    • Section 

    • Employment Application

    • Desired Position:*

    • General Information

    • Date:*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Date of Birth:*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Are you currently employed?*

    • Education

    • Profession

    • Date of Expiration:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Date of Expiration:
       - -
      2 digit month, 2 digit day, 4 digit year

    • Employment History

    • Time Employed (Mo. & Yr.)

    • Format: (000) 000-0000.
    • May we contact this employer?*

    • Time Employed (Mo. & Yr.)

    • Format: (000) 000-0000.
    • May we contact this employer?*

    • Other

    • Have you ever been convicted of any law violation (except a minor traffic violation)?*
    • Are you now or do you expect to be engaged in any other business or employment?*

    • For Driving Jobs Only

    • Do you have a valid driver’s license?*
    • Have you had your driver’s license suspended or revoked in the last three years?*
    • Have you worked under any other name?*
    • Are you presently employed?*
    • May we contact your current employer?*
    • Have you ever been fired or asked to resign?*

    • I certify that the information on this application is true and complete to the best of my knowledge. I understand that any misrepresentation, willful omission, false or misleading information is grounds for rejection of this application form, refusal to hire, withdrawal of an offer of Employment, or immediate discharge whenever discovered. You are authorized to conduct investigations, including verification of prior employment history and education. I also understand that employment is dependent upon receipt of acceptable employment references and satisfactory completion of pre-employment health screening which will include illicit drug and alcohol testing and provision of documents required by the Immigration reform and Control Act of 1986. DIVINE HEALTHCARE LLC does not discriminate against any qualified person because of age, race, color, religion, sex, national origin, disability, sexual orientation, or any other applicable status protected by state or local law. By signing this application, I acknowledge that an offer of employment at DIVINE HEALTHCARE LLC should not be interpreted as an offer of continued or permanent employment. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

    • Date:*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Section 

    • EMPLOYEE AVAILABILITY

      Please provide the following information on your availability to work for DIVINE HEALTHCARE LLC.
    • Do you have any allergies that would affect your work?*
    • Are you willing to work in a home with cats?*
    • Are you willing to work in a home with dogs?*
    • Do you have a problem working with a client who smokes?*
    • Please Check (✓) the Day and Time of the Week You
      Rows
    • Section 

    • REQUEST FOR REFERENCE #1

    • Format: (000) 000-0000.
    • Employment Start Date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Employment End Date:
       - -
      2 digit month, 2 digit day, 4 digit year

    • The above-named applicant has applied for a position at DIVINE HEALTHCARE LLC and has given your name as a previous or current employer. Please complete this reference request and submit it to us. Thank you for your prompt reply.

      I, , on authorized and request my former/current employer, person given as a reference to answer all questions asked, and give all information requested concerning my work performance, character, and job-related skills.

    • FOR OFFICE USE ONLY
      Rows
    • Would you rehire this person?
    • Date:
       - -
      2 digit month, 2 digit day, 4 digit year

    • REQUEST FOR REFERENCE #2

    • Contact Method:
    • Format: (000) 000-0000.
    • Employment Start Date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Employment End Date:
       - -
      2 digit month, 2 digit day, 4 digit year

    • The above-named applicant has applied for a position at DIVINE HEALTHCARE LLC and has given your name as a previous or current employer. Please complete this reference request and submit it to us. Thank you for your prompt reply.

      I, , on authorized and request my former/current employer, person given as a reference to answer all questions asked, and give all information requested concerning my work performance, character, and job-related skills.

    • FOR OFFICE USE ONLY
      Rows
    • Would you rehire this person?
    • Date:
       - -
      2 digit month, 2 digit day, 4 digit year

    • REQUEST FOR REFERENCE #3

    • Contact Method:
    • Format: (000) 000-0000.
    • Employment Start Date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Employment End Date:
       - -
      2 digit month, 2 digit day, 4 digit year

    • The above-named applicant has applied for a position at DIVINE HEALTHCARE LLC and has given your name as a previous or current employer. Please complete this reference request and submit it to us. Thank you for your prompt reply.

      I, , on authorized and request my former/current employer, person given as a reference to answer all questions asked, and give all information requested concerning my work performance, character, and job-related skills.

    • FOR OFFICE USE ONLY
      Rows
    • Would you rehire this person?
    • Date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Section 

    • EMPLOYEE EMERGENCY INFORMATION

    • Contact Method:
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.

    • PERSON(S) TO CONTACT IN CASE OF EMERGENCY

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • EFFECTIVE DATE:
       - -
      2 digit month, 2 digit day, 4 digit year
    • DATE REVIEWED:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Section 

    • DRUG AND ALCOHOL POLICY AGREEMENT

    • It is the policy of DIVINE HEALTHCARE LLC that all its employees be free of the influence of alcohol and drugs. All employees must be fit for the duty physically and mentally, as is necessary to perform work in a safe and competent manner.

      Possession, trading, manufacture and sale of illegal drugs or alcohol on the job is therefore a violation of this policy.

      Also, it is a violation of this policy to work under the influence of illegal drugs or alcohol.
      Violations of this policy are subject to disciplinary action up to and including termination.

    • ACKNOWLEDGEMENT

    • I, certify that I am not under the influence of drugs or alcohol, nor will I use or possess in anyway controlled substances (marijuana, heroin, cocaine, crack, hash etc.) I understand that these examples do not cover all controlled substances. Failure to comply with this agreement may result in termination of my employment with DIVINE HEALTHCARE LLC. I have been briefed and fully understand DIVINE HEALTHCARE LLC drug and alcohol policy and I agree to fully comply with the provisions herein.

    • Date:*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Section 

    • EMPLOYMENT STATEMENT OF CONFIDENTIALITY

    • I, the undersigned, understand the importance of observing strict confidentiality policies. Therefore, I agree not to discuss / release any information obtained within the agency, any DIVINE HEALTHCARE LLC client, their medical records, or any client’s condition with any individual not directly associated with the client. I also agree that any information that is released regarding the client or the client’s record will only be done with proper authorization and / or in accordance with established agency policy for the release of the information.

      My signature on this document indicates that I understand and agree to abide by the aforementioned policies, and that any breach in the aforementioned policies will result in implementation of the Disciplinary procedure up to and including possible IMMEDIATE DISMISSAL from employment at DIVINE HEALTHCARE LLC.

    • Date:*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Section 
    • Should be Empty: