Employment Application for Personal Care Attendant

Employment Application for Personal Care Attendant
Please Select One:

Work For a Specific PersonBe Referred to Others
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN*
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Can you verify that you meet the following qualifications: Are you at least 18 years of age; able to meet the physical and mental demands required to perform specific tasks of the consumer; agree to maintain confidentiality; be emotionally mature and dependable;be able to handle emergency situations; and not be the consumer's spouse?

YesNo
Have you lived in Missouri for the past 5 years?

YesNo
Please list the State:
Do you smoke?

YesNo
How did you learn of this position?
Is there any reason why you would not be able to perform the job duties?

YesNo
Please explain why:
Background: A background screening via the FCRS must be performed prior to the first day. Have you been charged with an offense other than a minor traffic violation?

YesNo
Please disclose all criminal convictions, findings of guilt, plea of guilt,and pleas of nolo contendere or provide a statement there is no record of such background. Failure to disclose any criminal information is a violation of the law. If this do not apply, please type N/A
Are you registered with the Family Care Safety Registry?

YesNo
Have you applied for a Good Cause Waiver?

YesNo
When?

MonthDayYear
Date
Do you have a Skilled License?

YesNo
What type?
Do you have a valid Driver's License?

YesNo
Do you have transportation?

YesNo
Have you ever worked with persons with physical/cognitive disabilities?

YesNo
Please explain:
Preferences and Availability
Do you prefer working with males, females or either?
What days are you available?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Monday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Tuesday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Wednesday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Thursday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Friday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Saturday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Sunday

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Please check the following duties that you are willing and able to perform on a daily basis

DressingFeedingErrandsLaundryTransfersShoppingShoweringToilet RoutineHomeworkCleaningMeal PreparationCorrespondence
Employment History
Company Name
Supervisor
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Position
Company Phone Number
Please enter a valid phone number.
May we contact this employer?

YesNo
Eligible for re-hire?

YesNo
Do you want to add another company?

YesNo
Company Name
Supervisor
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Position
Company Phone Number
Please enter a valid phone number.
May we contact this employer?

YesNo
Eligible for re-hire?

YesNo
Do you want to add another company?

YesNo
Company Name
Supervisor
Employment Start Date

MonthDayYear
Date
Employment End Date

MonthDayYear
Date
Position
Company Phone Number
Please enter a valid phone number.
May we contact this employer?

YesNo
Eligible for re-hire?

YesNo
References

Provide three personal references that are not related to you
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
Phone Number
Please enter a valid phone number.
Do you want to add another reference?

YesNo
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
Phone Number
Please enter a valid phone number.
Do you want to add another reference?

YesNo
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
Phone Number
Please enter a valid phone number.
I certify that the answers given are true and complete to the best ofmy knowledge and I hereby grant permission for abackground screening via the FCSR to be performed for employment purposes.

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Date

MonthDayYear
Date
For Vendor Purposes Only: This applicant is blanks eligible orblank ineligible for employment according to the regulations and the FCSR background screening.
Screening performed by:
Comments:
Military Record
Branch of Service:
Rank/Discharge Date

MonthDayYear
Date
Have you ever been convicted of any criminal convictions, findings of guilt or plea of guilt?

YesNo
Plea of nolo contendere, except minor traffic violations?

YesNo
I give Allen Savvy Solution's consent to conduct a pre-employment criminal record check?

YesNo
Please explain
I give Allen Savvy Solution's consent to a closed record check pursuant to Sec. 610.210 RSMo?

YesNo
Please disclose all criminal convictions, if any please explain:
Authorization
I Certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed to give to you and all information concerning my previous employment and any pertinent information they may have, personal or or otherwise and release Allen Savvy Solution's from liability for any damage that may result from utilization of such information.
I also, understand and agree that no representative of Allen Savvy Solution's CDS has any authority to enter into an agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized agency representative
Attendant Signature

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Date

MonthDayYear
Date
Auth Token
eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJ1c2VySWQiOjE2MzIzNCwiYnVzaW5lc3NJZCI6MTExOTUsIk1lbWJlcklEIjoxNTU3OTcsInVzZXJuYW1lIjoiQVNBVlZZLkFkbWluIiwiZmlyc3ROYW1lIjoiU3VwcG9ydCIsImxhc3ROYW1lIjoiQW5rb3RhIiwiYXBpQWNjZXNzIjpmYWxzZSwiZXhwIjoyNTM0MDIyMTQ0MDB9.mrPM_XhYx8CG0Rr5vjGFBvq58wPbK3nU8iflgPAhRfQ
Document Type
worker
Submission Type
Caregiver Name
Should be Empty:

Employment Application for Personal Care Attendant

Preferences and Availability

Employment History

References

Military Record

Authorization