DLB HEALTH HOME SERVICES EMPLOYMENT APPLICATION

DLB HEALTH HOME SERVICES EMPLOYMENT APPLICATION

We are an equal opportunity/affirmative action employer dedicated to a policy of non-discrimination in employment on the basis of ace, color, age, religion, national origin, disability, veteran status, citizenship, or ancestry. Applicants are not required to provide formation prohibited by Federal, State/Provincial or Local Law.
Position Applying For:
Date of Application:

MonthDayYear
Date
Social Security Number:
Name

First NameMiddle NameLast Name
Maiden Name (If Applicable):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email
example@example.com
Previous Address (If current is less than 5 years)
Driver's License #
Expiration Date:

MonthDayYear
Date
Issued in what State:
Has your driver's license ever been revoked?

YesNo
If YES, please explain
Have you ever entered a plea of guilty or novo contendere to or been convicted of anything other than a minor traffic accident?

YesNo
If YES, please explain
Have you even been bonded?

YesNo
Have you ever been denied bond coverage?

YesNo
Are you a U.S. citizen?

YesNo
Are you authorized to work in the U.S.?

YesNo
Have you used any Alias?

YesNo
If YES, list all aliases you have used (include maiden names, married names, and other legal name changes).
Have you used any other social security numbers?

YesNo
If YES, list ALL social security numbers you have ever used
Have you had any of the following in Missouri or any other state? • Criminal convictions finding of guilty, pleas of guilty, and pleas of nolo contendere (except minor traffic violations?

YesNo
If YES, list ALL criminal conviction, findings of guilty, and pleas of nolo contendere AND the state in which this occurred. Do not list minor traffic offenses, such as speeding and parking tickets.
How did you learn about us?

AdvertisingRelativeWalk InOther
Have you ever been employed with us before?

YesNo
If yes, give date(s)
Are you currently employed?

YesNo
If yes, may we contact your present employer?

YesNo
Date of Employment:

MonthDayYear
Date
Duties:
Reason for leaving:
Are you eligible for rehire?

YesNo
Availability

Full TimePart Time
DAYS AND TIMES AVAILABLE TO WORK

No PreferenceMondayTuesdayWednesdayThursdayFridaySaturdaySunday
How many hours can you work weekly?
Can you work nights?

YesNo
Date available to begin:

MonthDayYear
Date
What date would you be available to work?

MonthDayYear
Date
Are you able to handle emergency type situations and maintain confidentiality?

YesNo
Are you certified in CPR?

YesNo
If yes, Effective Date
if yes, Due On
What starting salary do you expect? Per Hour
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? (Proof of Citizenship or Immigration status will be required upon employment)

YesNo
Are you currently registered with the Family Care Safety Registry?

YesNo
If No, do you consent to become registered with the Family Care Safety Registry?(Failure to check "Yes" for consent will result in a denial of employment)

YesNo
Do you have a disqualifying event that would be included in the Family Care Safety Registry?

YesNo
No applicant can be employed by DLB Health, LLC until they pass a screening of the Employee Disqualification Lis EDL) and until we have obtained a clean background check on the application from the Family Care Safety Registr (FCSR). There will be a $15.00 non-refundable registration fee for employees to be screened and registered.
If applicant has certain offenses listed on the FCSR background check, the applicant may apply for a "Good Cause Waiver' to the Missouri Dept. Of Health and Senior Services (DHSS). DHSS may grant (approve) a "Good Cause Waiver" at their discretion.

Anyone listed on the EDL will not, under any circumstances, be employed by DLB Health, LLC. The FCSR will be checked twice a year. The EDL will be checked four times a year (this includes the checks done through the FCSR). If any new findings appear on either of these background screenings, the attendant will no longer be able to be employed by DLB Health, LLC.

The employee will receive a copy of these background checks from DHSS and FCSR at least twice a year.
Do you consent to an open and closed record check?

YesNo
Do you consent for a pre-employment criminal record check?

YesNo
Do you consent to a closed background check, pursuant to SECTION 610.120 RSMo?

YesNo
Are you currently employed with another In-Home Service Provider or Home Health Agency?

YesNo
If YES, who is your present employer?
Do you have a relative(s) currently employed by us?

YesNo
If YES, who?
Are you related either by marriage or blood to a client receiving our services?

YesNo
If YES, who?
Have you ever been a resident of or employed in another state?

YesNo
If YES, where and what date?
Are you 18 years of age or older?

YesNo
Are you able to lift, push, pull or carry up to 75 pounds and twist, bend, stoop, and climb stairs without difficulty?

YesNo
This job requires consistent regular and punctual attendance; can you meet this requirement?

YesNo
Have you served in the United States military? If YES, please provide the following information:

YesNo
Branch of Service:
Date of Service:

MonthDayYear
Date
Rank of Discharge:
Type of Discharge:
Was Discharge Honorable?

YesNo
If NO, explain:
Have you ever had any job-related training in the United States Military?

YesNo
Describe and date below any non-paid volunteer work experience (exclude organizations, the name of charter of which would indicate the race, sex, religion, national origin or disability of its members)

DRIVER'S INFORMATION
This job requires you to have a dependable vehicle. Are you currently in possession of one?

YesNo
Are you currently in possession of Automobile Insurance that meets the statutory insurance requirements for the State of Missouri?

YesNo
Is this Insurance currently in effect?

YesNo
Driver's License #:
Issuing State:
Exp Date:

MonthDayYear
Date
Class:

EMPLOYMENT EXPERIENCE
Start with your present or most recent employment. You MUST list at least 5 years of employment history.
Employer Name
Job Title
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor/Manager Name:
Supervisor/Manager Phone Number:
Please enter a valid phone number.
Dates Employed From - To
Wage / Per (Hour/Week/Year)
Description of Job Duties:
Reason for Leaving:
Employer Name
Job Title
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor/Manager Name:
Supervisor/Manager Phone Number:
Please enter a valid phone number.
Dates Employed From - To
Wage / Per (Hour/Week/Year)
Description of Job Duties:
Reason for Leaving:
Employer Name
Job Title
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor/Manager Name:
Supervisor/Manager Phone Number:
Please enter a valid phone number.
Dates Employed From - To
Wage / Per (Hour/Week/Year)
Description of Job Duties:
Reason for Leaving:
Employer Name
Job Title
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor/Manager Name:
Supervisor/Manager Phone Number:
Please enter a valid phone number.
Dates Employed From - To
Wage / Per (Hour/Week/Year)
Description of Job Duties:
Reason for Leaving:
Please explain any gaps in your employment history:

EDUCATION AND TRAINING
Elementary
Date(s) Attended
Graduate

YesNo
Diploma/Degree/Study
High School
Date(s) Attended
Graduate

YesNo
Diploma/Degree/Study
College/University
Date(s) Attended
Graduate

YesNo
Diploma/Degree/Study
Other
Date(s) Attended
Graduate

YesNo
Diploma/Degree/Study

EMPLOYMENT REFERENCE 1
**ALL APPLICANTS MUST HAVE 2 EMPLOYMENT REFERENCES
Company Name:
Company Representative Name/Title:
Dates of Employment: START

MonthDayYear
Date
Dates of Employment: END

MonthDayYear
Date
Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Telephone Number:
Please enter a valid phone number.
Employment References must be verifiable. If not, you will need to provide additional references.

Office staff only
Reference Checked by:
Date:

MonthDayYear
Date
Manager Signature:
Date

MonthDayYear
Date

EMPLOYMENT REFERENCE 2
**ALL APPLICANTS MUST HAVE 2 EMPLOYMENT REFERENCES
Company Name:
Company Representative Name/Title:
Dates of Employment: Start

MonthDayYear
Date
Dates of Employment: End

MonthDayYear
Date
Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Telephone Number:
Please enter a valid phone number.
Employment References must be verifiable. If not, you will need to provide additional references.

Office staff only
Reference Checked by:
Date

MonthDayYear
Date
Manager Signature:
Date

MonthDayYear
Date
I, the applicant, verify that the information provided is true and correct to the best of my knowledge. I also acknowledge that a Criminal Conviction Check is required and that some convictions prevent employment.
Signature

Powered by Jotform SignClear
Date of Signature:

MonthDayYear
Date
Print Name

First NameLast Name
Should be Empty: