Tender Loving Touch Home Care, LLC
Warrenton, NC
Tel: (252)-879-8100
Fax: 252-879-8088
EMPLOYMENT APPLICATION.
Agency Information
Agency Name: TENDER LOVING TOUCH HOME CARE, LLC
Address: WARRENTON, NC
Phone Number: 252-879-8100
Email: TENDERLOVINGTOUCHHC@AOL.COM
Applicant Information
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Social Security Number:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Position Applying For:
RN
LPN
CNA
HHA
Companion
PCA
Other
Date Available to Start:
*
-
Month
-
Day
Year
Date
Desired Salary:
*
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Work Eligibility & Background (answer all)
Are you legally authorized to work in the United States?
*
Yes
No
Have you ever worked for this agency before? If yes, when/position:
Yes
No
If yes, when/position
Are you at least 18 years of age? (For driving clients: at least 21 and valid license)
*
Yes
No
Can you perform the essential functions of the job with or without reasonable accommodation?
Yes
No
Have you been excluded from participating in Medicare/Medicaid?
*
Yes
No
Are you legally eligible to work in the U.S.?
*
Yes
No
Have you ever worked for a home care agency before?
Yes
No
If yes, explain:
Licensure / Certification
License/Certification Type:
*
Number:
State Issued:
*
Expiration Date:
-
Month
-
Day
Year
Date
Education
EDUCATION HISTORY.
*
Untitled Matrix
Rows
Employment History (Last 3 Employers)
Employer #1
Company Name:
*
Job Title:
*
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
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Supervisor Name & Contact:
*
Reason for Leaving:
Employer #2
Company Name:
*
Job Title:
*
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Supervisor Name & Contact:
*
Reason for Leaving:
Employer #3
Company Name:
*
Job Title:
*
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Supervisor Name & Contact:
*
Reason for Leaving:
References (3) (PROFESSIONAL)
Name Relationship Phone Number Email
PLEASE LIST 3 REFERENCES:
*
Criminal Background and Health Screening
Have you ever been convicted of a felony or misdemeanor (excluding minor traffic violations)?
*
Yes
No
If yes, explain:
Are you willing to undergo a drug screening and TB test?
*
Yes
No
Have you had a physical exam in the last 12 months?
Yes
No
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Emergency Contact
Name:
*
Relationship:
Phone Number:
*
Format: (000) 000-0000.
Address:
Applicant Signature
I certify that the information provided in this application is true and complete. I understand that any misrepresentation or omission may disqualify me from employment or, if employed, may result in termination. I authorize the agency to verify all statements, including contacting former employers and references. I understand that employment, if offered, is at-will, meaning that either I or the agency may terminate the employment relationship at any time, with or without cause or notice, subject to applicable law and any written contract. I acknowledge that nothing in this application or in any agency communication creates a contract of employment for any specific duration.
Applicant Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Printed Name:
*
DISCLOSURE: Tender Loving Touch Home Care, LLC may obtain background reports (consumer reports and/or investigative consumer reports) about you for employment purposes. These reports may include information about your criminal history, driving record (MVR), education and employment verifications, professional licensure, sanctions/exclusions, and other public record information. The reports may also include personal interviews regarding your character, general reputation, personal characteristics, or mode of living.
AUTHORIZATION: By signing below, you authorize the agency to obtain consumer reports and/or investigative consumer reports at any time after receipt of this authorization and, if hired, throughout your employment, as allowed by law. You authorize all law enforcement agencies, educational institutions, former employers, personal references, and any other sources to release information to the background screening provider and the agency.
Full Legal Name:
*
Date of Birth*:
*
-
Month
-
Day
Year
Date
Other Names Used:
Current Address:
City/State/ZIP:
From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
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Driver's License #:
*
State:
*DOB requested solely for accurate
background check identification and not for discriminatory purposes.
Signature:
*
Date:
-
Month
-
Day
Year
Date
This Disclosure & Authorization is intended to be a standalone document. The agency will provide additional
state/federal notices as required.
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