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EMPLOYMENT APPLICATION

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

  •  Please read "Applicant Note” below.

  • Complete all pages of this application.

  • Print clearly. Incomplete or illegible applications may not be accepted.

  •  If more space is needed to complete any question, use comments section on the back.  Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with our Home Care Agency. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

EMPLOYMENT / JOB APPLICATION

PERSONAL INFORMATION

Date Available
Month
Day
Year
Employment Desired

Employment Eligibility

Are you legally eligible to work in the US?
Have you ever worked for this employer?
Have you ever been convicted of a felony?

Education

Graduate?
Graduate

Previous Employment

Starting Pay
Hourly
Salary
Ending Pay
Hourly
Salary
Starting Pay
Hourly
Salary
Ending Pay
Hourly
Salary
Starting Pay
Hourly
Salary
Ending Pay
Hourly
Salary

References (Professional Only)

PROFESSIONAL REFERENCES CONTINUED ...

Background Check Consent

IF YOU ARE ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK?
YES
NO

DISCLAIMER

Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

Date
Month
Day
Year

Applicant Notice:

It is illegal in Philadelphia for employers to ask about your criminal background during the job application process.

Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depend on the results of your background check).

  • Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting time of incarceration).

  • Arrests that did not lead to conviction cannot be used in any employment decisions.

  • If your background check reveals a conviction, the employer must consider:

    The type of offense and the time that has passed since it occurred.

    Its connection to the job you’re applying for; and

  • Your job history, character references, and any evidence of rehabilitation.

  • Employers can reject you based on your criminal record ONLY if you pose an

    unacceptable risk to the business or to other people.

  • If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision.

  • You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.


APPLICANT CERTIFICATION AND RELEASE:

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.

I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations.

I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

Date
Month
Day
Year

DIRECT CARE WORKER AVAILABILITY FORM

Please complete the following schedule and provide times that you are able to work for CCHC. We provide services 24 hours a day, 7 days a week. How you complete this form is especially important. The work hours that are provided for you by CCHC are driven by two primary business issues; the needs of the Consumers and your availability to work.

TOTAL REQUESTED HOURS PER WEEK:

**l understands that the more I am available to work the greater likelihood that my hours request will be met.

ADDITIONAL AVAILABILITY:

Are you willing to do temporary fill-in hours?
Yes
No
Are you available to be On-Call for additional income?
Yes
No
Are you willing to work with Consumers who smoke?
Yes
No
Are you willing to work with Consumers who have pets?
Yes
No

This sheet designates the times that I am committing myself to be available to work for CCHC. By signing this sheet, I acknowledge that the decision to hire me will be based in part on the above availability. I agree any changes to my availability must be approved and signed by my supervisor. I understand that there is no guarantee of hours if I am offered a position with CCHC. I understand that it can take time to reach and sustain my desired number of hours per" week and that multiple factors affect this goal including my availability, Consumer requests, my stalls, and my ability to please the Consumer to whom I am assigned. Nothing in this statement is to be construed as a direct, implied or inferred contract of employment. I understand I am not authorized to provide medical care independently and agree that if a medical emergency arises while I am with a Consumer, I will call 911 and follow their instructions accordingly.

Date
Month
Day
Year
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