Employment Application (Caregivers)

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature
Date

MonthDayYear
Date

Care Provider Background Screening Clearinghouse Background Screening Request Form
You have applied for a position with a health care and/or service provider regulated by a specified agency in the Care Provider Background Screening Clearinghouse (Clearinghouse) that requires a fingerprint-based background check. As a health care and/or service provider regulated by a specified agency in the Clearinghouse we may conduct a search for an existing background screening result or submit a new background screening request through the Clearinghouse results website on your behalf. In order to complete the search and/or background screening request we must collect the following information. This information is required by the Clearinghouse, the Florida Department of Law Enforcement, and the Federal Bureau of Investigation. Please provide the following information:
Applicant Information:
Full Name

First NameMiddle NameLast Name
Aliases:
SSN:
Date of Birth:

MonthDayYear
Date
Place of Birth:
Demographics
Sex:
Race:
Hair Color:
Eye Color:
Height:
Weight:
Contact Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:
Prior States:
Email:
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
*Denotes Required Fields

Employment Verification Authorization
Please provide my employment dates for verification purposes to Rehoboth Home Care services (RHC) as requested.
Signature
Printed Name:
Date

MonthDayYear
Date
Should be Empty:

Education