Employment Application - Crescent Home Health Agency

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Note: Please complete each section and print legibly except where signatures are required

Crescent Home Care, LLC. is an equal opportunity employer and affords equal opportunity to all applicants without regard to race, color, religion, gender, national origin, age, disability, veteran status, marital or family status, genetic information or any other statuses protected under local, state, or Federal law.

Please Print Clearly and Legibly

NAME

ADDRESS

Street Address CITY STATE ZIP

SOCIAL SECURITY #

DATE OF BIRTH

MM slash DD slash YYYY

TELEPHONE NUMBERS:

Home

Cell

Work

DRIVER’S LICENSE STATE

DRIVER'S LICENSE NUMBER

NON-DRIVER'S LICENSE STATE

NON-DRIVER'S LICENSE NUMBER

Are you are at least 18 years of age or older?

Yes

Are able to meet the physical and mental demands required to perform specific tasks for the client?

Yes

Do you agree to maintain confidentiality?

Yes

Are you emotionally mature and dependable?

Yes

Are you able to handle emergency situations?

Yes

Have you lived in Missouri for the past 5 years?

Yes

If No, please list the state(s) you have lived in

How did you learn of this position?

Is there any reason why you would not be able to perform the job duties?

Yes

If Yes, please explain below

All persons applying for employment with Crescent Home Care, LLC., are subjected to background screenings via the Family Care Safety Registry and Employee Disqualification List. These screenings will be completed prior to your first day of employment. PLEASE read the following questions, provide true and accurate information.

HAVE YOU HAD ANY OF THE FOLLOWING IN MISSOURI OR IN ANY OTHER STATE: criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo contendere?

Yes

If YES, list ALL criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo contendere AND the state in which this occurred. Do not list minor traffic offenses such as speeding tickets and parking tickets. If this does not apply, please use N/A. List the offense and date for each crime

Do you give Crescent Home Care, LLC., consent to conduct a pre-employment criminal record check?

Yes

If No, please explain

Do you authorize Crescent Home Care, LLC to conduct a closed record check pursuant to Section 610.120, RSMO?

Yes

If No, please explain

Have you ever used an alias?

Yes

If YES, list ALL aliases you have used (please include maiden names, married names, and other legal name changes).

Have you used any other social security numbers other than the name and social security number you used on this application?

Yes

If Yes, please list all social security numbers used:

Are you registered with the Family Care Safety Registry?

Yes

If applicable, have you applied for a Good Cause Waiver?

Yes

If YES, When?

Are you listed on the Employee Disqualification List (EDL)?

Yes

Do you have a Skilled License?

Yes

If YES, what type?

Provide a copy

Max. file size: 512 MB.

Do you have transportation?

Yes

Have you ever worked with persons with physical and/or developmental disabilities?

Yes

If yes, Please explain

Preferences and Availability

Do you prefer working with males, females or either?

What days and hours are you available?

Sun

Mon

Tue

Wed

Thurs

Fri

Sat

Please check the following duties that you are willing and able to perform daily:

Dressing

Grooming

Errands

Laundry

Transfers

Shopping

Bathing/Showering

Toileting Routine

Correspondence

Housekeeping

Meal Preparation

Employment History: (your signature on this application gives us permission to contact the employers you have listed)

Company Name

Phone

Supervisor

Position

Date Employed

From

MM slash DD slash YYYY

May we contact this employer?

Yes

Duties

Reason for leaving

Are you eligible for re-hire?

Yes

Rate of Pay: $

/hour

References: (your signature on this application gives us permission to contact your references)

Name/Title

Phone

Address

E-mail

Name/Title

Phone

Address

E-mail

Name/Title

Phone

Address

E-mail

Education and Training

Name/Location of High School

Diploma Received?

Yes

If Yes, Year Received

Other (Please list)

College/University or Professional School

Degree or Certification Received/Year

Please provide Crescent Home Care, LLC with a copy of your driver's license, social security card and any certifications or licenses you may hold.

I certify that all the information provided by me on this application and accompanying documents is true and complete. I understand that false representation or omission of any fact will be cause for denial of employment or termination of employment.

I understand that if offered a position with Crescent Home Care, LLC. may be required to submit to a pre-employment drug screening.

Signature of Applicant

Date

MM slash DD slash YYYY

For Office Use ONLY:

Staff Member Start Date

MM slash DD slash YYYY

Rate of Pay $