Employment Form Step 1 of 9 11% PhoneThis field is for validation purposes and should be left unchanged.Qualifications for HireEmployee is at least 18 years of age. I confirm Employee is able to read, write, and follow instructions. I confirm Please check all past experiences that applyHas at least six months paid experience as: Agency Homemaker Nurse Aide Maid Has at least one year experience (paid or unpaid): Caring for Children Elderly Infirm Has successfully completed training as: Certified Nurse Aide LPN RN Interview NotesWe sometimes offer shifts on short notice. Would this be a problem? Yes No We must sometimes transfer heavy clients. Are you able to lift over 50 lbs.? Yes No Please give an example of your dependabilityHave you ever had to work with a difficult person? If so please explain how you handled working with this individualWhat is your 5 year goal plan?What is your availability?Please check the following counties in which you are available to work: Wyandotte Johnson Leavenworth Miami Douglas Franklin Linn Atchison Jefferson We do not discriminate on the basis of race, color, religion, national origin, sex, age, or disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. I certify that all information provided in this employment mployment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I Agree I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed orr not, not, any person, school, current employer, past employer and organization to pro I Agree I understand that if I am extended an offer of employment, it may be conditioned upon my successfully passing a complete pre-employment physical examination, my submitting a current negative tuberculosis test and my completion of any pre-employment mandatory training. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I Agree I also understand that I will be subject to a criminal background investigation, adult abuse registry check, and child abuse registry check prior to employment. I Agree I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. IUNDERSTAND THAT IF A CLIENT IS REMOVED FROM SERVICE, OR REQUESTS AN ALTERNATE WORKER, THERE IS NOTHING THAT ALLIANCE HOME HEALTH CARE, INC. CAN DO TO ALTER THE SITUATION. THIS SITUATION DOES NOT CONSTITUTE A TERMINATION OR RELEASE OF EMPLOYMENT ON THE PART OF ALLIANCE HOME HEALTH CARE, INC. AND THEREFORE DOES NOT ENTITLE THE EMPLOYEE TO UNEMPLOYMENT COMPENSATION. IF AN EMPLOYEE LOSES HOURS FOR ANY REASON IT IS THEIR RESPONSIBILITY TO CONTACT THE OFFICE EXPRESSING THEIR DESIRE FOR ADDITIONAL WORK. FAILURE TO DO SO WILL BE INTERPRETED AS A VOLUNTARY TERMINATION OF EMPLOYMENT. BY SIGNING BELOW, I ACKNOWLEDGE THAT THERE IS NO GUARANTEE ON THE AVAILABILITY, REGULARITY, OR TIMELINESS OF EMPLOYMENT HOURS I Agree I have read, understand, and by my signature consent to these statements. This application for employment will remain active for a limited time. Ask the organization representative for details. I Agree Signature Personal InformationName First Middle Last Other Names Used (Include aliases, maiden & nick names)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneSocial Security #SSN Verification I confirm Criminal Background Report I confirm Have you used any names or Social Security Numbers other than given above? Yes No List Here:Employment DesiredPosition(s) Applied ForDate of Application Are you currently employed? Yes No May we contact your present employer? Yes No Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? Yes No Explain:On what date would you be available for work?Have you ever been convicted of any law violation? (Include any plea of guilty or no contest. Exclude minor traffic violations.) Note: A conviction will not necessarily disqualify an applicant for employment. Yes No Gives Dates, Court Locations and Sentence.Are you free for assignment anywhere in the world, as occasion demand Yes No Explain NameEmployment Experience List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from current and former employers. Employment Experience 1Employer (Current or last)Employed From Employed To Hourly Rate/Salary StartHourly Rate/Salary FinalAddressCity/State/ZipPhoneEmployment Verification Yes No Job Title and DutiesSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for LeavingEmployment Experience 2Employer (Current or last)Employed From Employed To Hourly Rate/Salary StartHourly Rate/Salary FinalAddressCity/State/ZipPhoneEmployment Verification Yes No Job Title and DutiesSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for LeavingEmployment Experience 3Employer (Current or last)Employed From Employed To Hourly Rate/Salary StartHourly Rate/Salary FinalAddressCity/State/ZipPhoneEmployment Verification Yes No Job Title and DutiesSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for LeavingEmployment Experience 4Employer (Current or last)Employed From Employed To Hourly Rate/Salary StartHourly Rate/Salary FinalAddressCity/State/ZipPhoneEmployment Verification Yes No Job Title and DutiesSupervisor NameDepartmentCo-Worker NameDepartmentCo-Worker NameDepartmentReason for Leaving EducationHigh SchoolName and Location of School (Location should be name of City, State, Zip)From Date To Date Graduate? Yes No College or UniversityName and Location of School (Location should be name of City, State, Zip)From Date To Date List Professional Licenses or CredentialsEducation Verification Yes No References List below the names of four persons not related to you whom you have known at least one year: Reference 1NamePhoneAddressPersonal References Yes Reference 2NamePhoneAddressPersonal References Yes Reference 3NamePhoneAddressPersonal References Yes Reference 4NamePhoneAddressPersonal References Yes Emergency ContactNameRelationship to the ApplicantPhone NumberEmail Address Address Street Address City State / Province / Region ZIP / Postal Code Previous EmploymentCompany NameAddress Street Address City State / Province / Region ZIP / Postal Code PhoneSupervisorFrom Date To Date Reason for leavingBy Signing this document below I, in order to obtain employment with Alliance Home Health Care, Inc., hereby authorize you to supply the information requested below. I waive any possible claim against you or your organization and agree to release you from any liability regarding the provision of such information. I Agree Applicant NamePosition Applied ForAddress Street Address City State / Province / Region ZIP / Postal Code Applicant Signature FACILITY NAME: Alliance Home Health Care, Inc. FACILITY I D # A105045 ADDRESS: 1831 Minnesota Ave CITY: Kansas City STATE: Kansas ZIP CODE: 66102 Applicant information: ALL REQUESTED INFORMAT ION MUST BE PROVIDED or the form will not be processed.Name First Middle Last Suffix Other Names Ever UsedLast Name** List additional names on back. Check here if more on back. Yes Social Security NumberDate of Birth SexRaceOne of the following must be selected A- Asian or Pacific Islander B- Black I- Native American/Alaskan Native W- White Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Post Office Box # (if applicable)Home PhoneWork PhoneCertificate# (if applicable)Job Classification: Determine the correct job classification for the applicant and Insert the three letter abbreviation in the box. Job Classification Abbreviation Activities Staff ACS Food Service Worker FSW Medical Records Staff MRS Administrator ADM Home Health Aide HHA Operator OPR Business and Administrative BAS Home Health Aide Trainee HHT Paid Driver DRV Certified Medication Aide CMA Housekeeping HSK Paid Nutrition Assistant PNA Certified Nurse Aide CNA Human Resources Staff HRS Personnel Staff PER Nurse Aide Trainee NAT Laundry Workers LDW Restorative Aide RSA Chaplain CHN Maintenance Worker MTW Social Service Designee SSD Clerical Staff CLS Marketing Staff MKT Volunteer Coordinator VLC Wellness Staff WEL Completed by Date I give permission to check my personal information against the following registries: Child ($10 per person) Adult (Free) I give permission for the release of any of my information in the Child and/or Adult Abuse/Neglect Central Registry to the contacts listed above. I understand the information released is for their exclusive and confidential use. No Confidentiality: Kansas Department for Children and Families' records are confidential. No individual, association, partnership, corporation or other entity shall willfully or knowingly disclose, permit or encourage disclosure of the contents of records or reports in violation of the confidentiality requirements of K.S.A. 38-2209. Violation of this statute is a Class A nonperson misdemeanor, and the court may impose a civil penalty of up to $1,000. Name First Middle Last Other Names UsedDate of Birth RaceSocial Security NumberGender Male Female Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone NumberEmail Signature*Signature must be ink or electronically verified by a reputable company. Applicant is under the age of 16 and I am (relationship to applicant)Results will be sent electronically. *This form is to remain on file for the duration of the active relationship between the agency and the person being searched. DCF reserves the right to audit at any time to make sure all forms are up to date and on file.
