Applicants for employment are considered without regard to race, religion, color, national origin, age, sex, disability, sexual orientation, or veteran's status. may conduct a background check on each applicant. This is an at-will employment agency, and any offer of employment is conditional and subject to the receipt, review, and disposition of applicant's background check, drug & alcohol testing, central registry clearance, and successful completion of any required training.

Referral Source: Social Media, Friend, Relative, Employment Agency, Walk-In

Have you ever filed an application here before?

Have you ever been employed here before?

Are you currently employed? Yes or No

If yes, may we contact your employer? Yes or No

Are you a United States citizen? Yes permit? Yes (Proof of citizenship or immigration status may be required upon employment)

No If no, do you have a valid work permit?

 

Within the past five years, have you been convicted of a felony or misdemeanor?

NUMBER MAJOR OF DEGREE YEARS COMPLETED

DRIVER'S LICENSE (Only for positions which require driving)

Do you have a driver's license?

Have you had any accidents during the past three years?

Have you had any moving violations during the past three years? Yes No

Are you a veteran of the United States military service?

Please list your work experiences for the past 5 years, beginning with your most recent job and thereafter in descending order. If there were any gaps in employment, please explain. If you were self-employed, provide your firm's name. Attach additional sheets if necessary. Exclude organization names which indicate race, religion, national origin, age, sex, disability, sexual orientation, or veteran's status. Work Performed Dates Most Recent Employer Employed From:

 

APPLICATION WILL BE DENIED IF A FULL FIVE YEAR HISTORY IS NOT PROVIDED

Please list two references other than relatives or previous employers.

Please read each section carefully and sign where indicated.

It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of.

CERTIFICATION OF TRUTH AND ACCURACY

I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.

iCHERISH HOME CARE SERVICES, LLC abides by HIPAA guidelines regarding confidentiality. All staff members are required to avoid discussions of any organizational matters in public places or areas where others present are able to overhear the conversation pertaining to residents or patients and their perspective care. All records, reports and information concerning the residents or patients of this organization are to be treated with the utmost confidentiality Failure to observe these HIPAA guidelines is grounds for automatic termination.

I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the job. I understand that I will also be required to undergo a pre-employment medical exam and post-employment annual medical exam.

NOTIFICATION AND AUTHORIZATION TO REQUIRE A MEDICAL EXAMINATION

NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION

I understand that I may be subject to a background check, and hereby authorize the identified agent for the organization to investigate my background to determine any and all information of concern as to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information. Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records, and criminal records. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required. I further understand that any employment offered is contingent upon my background investigation results being free of any criminal felony or misdemeanor offenses. Furthermore, I understand that any employment offered may be rescinded pending the outcome of these findings.

CONSENT FOR DRUG AND ALCOHOL TESTING

If you are offered and accept employment with in the interest of safety for all concerned and AS A CONDITION OF EMPLOYMENT, you will be required to take a urine test for drug and/or alcohol use.

I (applicant) have been fully informed of the reason for this urine test for drug and/or alcohol (I understand what I am being tested for), the procedure involved, and do hereby freely give my consent. In addition, I understand that the results of this test will be forwarded to and become part of my EMPLOYMENT record. If this test is positive, I fully understand that the conditional offers of employment will be rescinded.

I further understand that at any given time, I may be asked to take a drug and alcohol test and that a positive result of any non-prescriptive substance may result in my termination. I further understand that a refusal to give urine, failure to REPORT TO DESIGNATED TESTING SITE UPON REQUEST, and to fully/properly cooperate are grounds for automatic termination. I hereby authorize these test results to be released to this prospective employer.

iCHERISH HOME CARE SERVICES is committed to the principle of equal opportunity and employment. The organization does not discriminate on the basis of race, religion, color, national origin, age, sex, disability, sexual orientation, or veteran's status in admission to, access to, or treatment in, or employment in its program and activities. Any concerns regarding equal opportunity and employment should be directed to the administration office.