Be Intentional Home Health Care, LLC
ONLINE EMPLOYMENT APPLICATION

Applicants are not required to give information prohibited by Federal, State/Provincial or local law.

GENERAL INFORMATION

Today's Date:

Last Name

Social Security Number

First Name

Middle Initial

Current Address

Previous Address (if current address is less than 5 years)

Home Phone

Cell Phone

Other Phone

Driver's License Number

Is yes, please explain

EDUCATION AND TRAINING

High School Name

High School Address

GPA

1. Business/Trade School or College Name

Business, Trade School or College Address

GPA

2. Business/Trade School or College Name

Business, Trade School or College Address

GPA

3. Business/Trade School or College Name

Business, Trade School or College Address

GPA

4. Business/Trade School or College Name

Business, Trade School or College Address

GPA

What starting salary do you expect per hour?

WORK HISTORY: LIST MOST RECENT EMPLOYER FIRST, INCLUDE PART-TIME EMPLOYMENT

MOST RECENT POSITION:

Employment Dates To - From

Company Name & Address

Position Held

Immediate Supervisor

Reason for Leaving

Duties Performed

PREVIOUS POSITION:

Employment Dates To - From

Company Name & Address

Position Held

Immediate Supervisor

Reason for Leaving

Duties Performed

PREVIOUS POSITION:

Employment Dates To - From

Company Name & Address

Position Held

Immediate Supervisor

Reason for Leaving

Duties Performed

The information I have provided is complete and accurate to the best of my knowledge. I also understand that providing the information may disqualify me from further consideration. I also authorize this agency to make any investigation(s) of my personal, financial, and/or credit background (including, but no limited to) obtaining a credit report (also known as a "consumer report" under the Fair Credit Reporting Act/Consumer Reporting Act) for the purpose of evaluating my qualifications for employment. This authorization extends for twelve months from today's date.

Today's Date

BACKGROUND SCREENING

It is mandatory that all applicants be registered with the Missouri Department of Health and Senior Services' Family Care Safety Registry. My signature below provides authorization for Be Intentional Home Health Care, LLC to conduct a background screening on me. If I am not registered I will pay the Fourteen dollars ($14.00) and ($1.25) on dollar and twenty cent online registration fee or my paper registration can be mailed with a fee of fourteen dollars ($14.00). If there are findings in my screening, and I want to become an employee, I agree to complete "Good Cause Waiver" application prior to being hired by Be Intentional Home Health Care, LLC. Once complete, Be Intentional Home Health Care, LLC will receive a report from the Family Registry indicating a Good Cause Waiver has been received and a case opened on my behalf. The Department of Health and Senior Services may grant (approve) a "Good Cause Waiver" at their discretion. Be Intentional Home Health Care, LLC will not hire any attendant needing a "Good Cause Waiver" until the waiver is approved, no exceptions.

FCSR

The FCSR will be checked prior to hire and annually after hired.

E-Verify

Be Intentional Home Health Care, LLC is required by the Department of Homeland Security to verify employment eligibility for all newly hired employees regardless of citizenship.

EDL

The Employee Disqualification List (EDL) maintained by the Department of Health and Senior Services is a listing of individuals who have been determined to have: Abused or neglected a resident, patient, client, or consumer; misappropriated funds or property belonging to a resident, patient, client, or consumer; of falsified documentation verifying delivery of services to an in-home services client or consure. The EDL will be checked four times per year.

OIG

The OIG will be checked monthly.

No applicant can be employed by Be Intentional Home Health Care, LLC, until they pass a screening of the Employee Disqualifications List (EDL) and until Be Intentional Home Health Care, LLC has obtained a background check on the applicant from the Family Care Safety Registry (FCSR). Anyone listed on the EDL will not, under any circumstances, be employed by Be Intentional Home Health Care, LLC. If hired, the attendant will have a copy of the background check, OIG and EDL placed in their application file. If any new listing appear on either of these background checks, the attendant will no longer be able to be employed by Be Intentional Home Health Care, LLC.

I have read this policy and understand my employment is conditional pending the outcome of the Missouri Department of Health and Senior Services' final decision and determination. I also grant permission for you to verify my employment eligitbility through IG, E-Verify and EDL.

Printed Name

Today's Date

BACKGROUND SCREENING APPLICATION

First and Last Name

Address

Home Phone

Cell Phone

Date of Birt

Social Security Number

If yes, list all those names your have ever used (please include all maiden names and all married names.)

If yes, list all social security numbers you have ever used.

If yes, please list when.

If yes, list all criminal convictions, findings of guilt, and pleas of nolo contendere. Do not list minor traffic offenses, such as speeding and parking tickets.

An applicant who knowingly fails to disclose his or her criminal history as required in subsection 5 of this section is guilty of a class A misdemeanor. You may request a copy of your background screening. By checking this box, I certify that I have read the document carefully, understand it, and agree to it voluntarily and without duress. I agree that withholding any of the information requested in thus document or submitting false information in connection with this document constitutes valid grounds for termination.

Printed Name

Today's Date

Be Intentional Home Health Care, LLC ONLINE EMPLOYMENT APPLICATION

Thank you for your application someone will contact you soon.

Be Intentional Home Health Care, LLC
ONLINE EMPLOYMENT APPLICATION