PFF - Employment Application

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.

EMPLOYEE AVAILABILITY

Please provide the following information on your availability to work for DIVINE HEALTHCARE LLC.
Type of Transportation you have / will use for Client Visits:*
YesNo
YesNo
YesNo
YesNo
How many hours are you willing to work per week?*
Locations willing to work:

Please Check (✓) the Day and Time of the Week You

REQUEST FOR REFERENCE #1
Company Name:*
Telephone:*
Address:*
City:*
State:*
Zip:*
Applicant Name:
Employment Start Date:

MonthDayYear
Employment End Date:

MonthDayYear
Present
Position/Title:
Reason for Leaving:
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, For Office Use Only , on For Office Use Only 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	Excellent	Above Average	Average	Unsatisfactory (comment)
Quality of work
Time and attendance
Initiative/motivation
Relationship with coworker/supervisor
Job knowledge

YesNo
If no, why?
Other comments:
Supervisor Signature:
Date:

MonthDayYear
REQUEST FOR REFERENCE #2
EmailFaxTelephone
Company Name:
Telephone:
Address:
City:
State:
Zip:
Applicant Name:
Employment Start Date:

MonthDayYear
Employment End Date:

MonthDayYear
Present
Position/Title:
Reason for Leaving:
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, For Office Use Only , on For Office Use Only 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	Excellent	Above Average	Average	Unsatisfactory (comment)
Quality of work
Time and attendance
Initiative/motivation
Relationship with coworker/supervisor
Job knowledge

YesNo
If no, why?
Other comments:
Supervisor Signature:
Date:

MonthDayYear
REQUEST FOR REFERENCE #3
EmailFaxTelephone
Company Name:
Telephone:
Address:
City:
State:
Zip:
Applicant Name:
Employment Start Date:

MonthDayYear
Employment End Date:

MonthDayYear
Present
Position/Title:
Reason for Leaving:
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, For Office Use Only , on For Office Use Only 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	Excellent	Above Average	Average	Unsatisfactory (comment)
Quality of work
Time and attendance
Initiative/motivation
Relationship with coworker/supervisor
Job knowledge

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.
Employee Signature:*
Date:*

MonthDayYear

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.
Employee Signature:*
Date:*

MonthDayYear
Agency Representative Title:
Agency Representative Signature:
Date:

MonthDayYear

Employment Application