• Application for Employment

    OmaCare Home Care Service
  • Format: (000) 000-0000.

  • Employment History

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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  • Position & Availability

    Personal Care Assistants with Open Availability
  • Position Applying For
  • Employment Type Desired
  • Do you have reliable transportation?
  • Do you have a valid driver's license?
  • Do you maintain current automobile insurance?*
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  • Caregiving Experience & Qualifications

    Please provide information regarding your caregiving experience, skills, and qualifications.
  • Do You Have Previous Caregiving Experience?
  • Have you cared for clients with any of the following conditions? (Check all that apply)
  • Which caregiving tasks are you comfortable performing? (Check all that apply)
  • Are you able to safely lift or assist clients with mobility?*

  • OmaCare Home Care Service – Employment Acknowledgments

  • BACKGROUND CHECK AUTHORIZATION

    I authorize OmaCare Home Care Service to obtain information regarding my criminal history, employment history, professional references, and any other background information necessary to determine my eligibility for employment. I understand that this information may be used as part of the hiring process.

    I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may result in denial of employment or termination if hired.

    By signing below, I voluntarily consent to this background investigation and verification process.

  • Date Signed*
     - -

  • HIPAA & CONFIDENTIALITY AGREEMENT

    I understand that, if employed, I may have access to confidential client information. I agree to maintain the privacy and confidentiality of all client records and information in accordance with HIPAA regulations, state laws, and OmaCare Home Care Service policies.

    I understand that unauthorized disclosure of confidential information may result in disciplinary action, up to and including termination of employment.

  • Date Signed*
     - -

  • AT-WILL EMPLOYMENT ACKNOWLEDGMENT

    I understand that employment with OmaCare Home Care Service is at-will. This means that either I or OmaCare Home Care Service may terminate the employment relationship at any time, with or without cause or notice, subject to applicable law.

    No representative of OmaCare Home Care Service has authority to enter into any agreement contrary to this at-will relationship unless it is in writing and signed by authorized management.

  • Date Signed*
     - -

  • CERTIFICATION STATEMENT

    I certify that all information provided in this employment application and supporting documents is true, accurate, and complete to the best of my knowledge. I understand that any falsification, omission, or misrepresentation may result in denial of employment or termination if discovered after hire.

  • Date Signed*
     - -
  • Should be Empty: