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  • EMPLOYMENT APPLICATION 

    Personal Care Attendants & Caregivers

    Heart of Humanity is An Equal Opportunity Employer. Applications are considered for all positions of employment wihtout regard to race, color, religion, sex, gender identificaiton, national origin, age, marital or veteran status, or non-job-related medical condidition or handicap.

  • Which location are you applying for?*

  • Personal Information

  • Format: (000) 000-0000.
  • Todays Date*
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  • Are you authorized to work in the U.S?*
  • Are you prevented from lawfully becoming employed in this country because of via or immigration status? (Proof of citizenship or immigration status will be required upon employment)*
  • Are you above 18 years of age?*
  • Format: 000-00-0000.
  • How were you referred to our company/organization?*

  • Education & Military Experience

  • Certificate
  • Have you served in the US Armed Forces?*
  • PLEASE CHECK APPROPRIATE BOX AND SIGN IF YOU WISH TO BE IDENTIFIED
  • Do you have experience caring for adults with special needs?*
  • Do you have experience caring for children with special needs?*
  • Do you have experience caring for elderly clients?*
  • Type of Position applying for*
  • Date you can start?*
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  • How many hours per shift are you available?*
  • What days are you available?*
  • Are you available for day time hours or overnight?*
  • Please select if you are allergic to the following:*
  • Client Preference*

  • Transportation

  • Do you drive?*
  • Are you willing to drive a client in your car?*
  • Are you willing to drive a clients car?*
  • Do you have a reliable transportation?*
  • Which areas are you willing to work?*
  • Expiration Date
     / /

  • Abuse Investigation

  • Have you ever been investigated for abuse, neglect or domestic violence?*

  • Work History

  • Start Date*
     - -
  • End Date
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  • May we contact this employer for a reference?*
  • Start Date*
     - -
  • End Date*
     - -
  • May we contact this employer for a reference?*
  • Have you ever been fired, dismissed, terminated or had an employment contract terminated for performance or disciplinary reasons?*

  • Certifications

  • Do you have a Home Care Organization Registry Number/PER ID?*
  • Do you have an active CPR Certification?*

  • References

  • Format: (000) 000-0000.
  • May we contact this individual for a reference?*
  • Format: (000) 000-0000.
  • May we contact this individual for a reference?*

  • New Hire Job Requirements [TAKE SCREENSHOT]

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     Dear Employee, the following is required upon hire:

    1. Current PPD (TB skin test or chest x-ray) dated within last 12 months
    2. Current CPR card (Cardiopulmonary Resuscitation)
    3. Current Driver License or State ID card
    4. Social Security Card, Permanent Resident Card, U.S. Passport or other acceptable document(s) for Employment Eligibility Verification (1-9)
    5. Current Automobile Insurance with expiration date
    6. Current Work References (2 are required)
    7. Live Scan Report/HCO Registry Number
    8. Signed Employment Application
    9. Complete Personnel Packet
    10. Complete Orientation (in office) 

  • Submit Application:

  •  

    By clicking the submit button below, I authorize former employers, references and any other individual/organizations to provide information to Heart of Humanity Health Services Inc., and I hereby release and discharge any of the above and release Heart of Humanity Health Services Inc. from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary. 

    I agree to a criminal background check, fingerprint, physical examination if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with Heart of Humanity Health Services Inc.

    I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or currently authorized to work in the United States.

    In consideration of my employment, I hereby certify that the information provided in this Application for Employment is true, correct and complete to the best of my knowledge. I understand that:

    • This application is not a contract of employment. Nothing contained in this application or conveyed during any interview which may be granted or during employment, if hired, is intended to create an employment contract between me and the employer. 
    • If employed, any false or misleading statements or any omission of fact made herein or during subsequent interviews, may result in dismissal.
    • Acceptance of an offer of employment does not create a contractual obligation upon the employer to continue my employment in the future.
    • I am required, if employed, to abide by all rules and regulations of the Company.

    I authorize any investigation of the information provided in this Application for Employment as may be required in reaching a decision regarding employment. If an investigative consumer reporting agency is engaged to report on my credit and personal history, I authorize you to do so. If a report is obtained, you must provide, at my request, the name and address of the agency so that I may obtain from them the nature and substance of the information contained in the report. In addition, I hereby release the employer, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

    I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application . I further agree in the event that I am hired by the employer, that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with the employer, whether during or after employment, including the solicitation or private hire of any employer clients will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written.

    I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at the option of the employer.

     

     
  • Date*
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