Employment Application -

First Name

Middle Name

Last Name

Date of Application *

Social Security Number *

Are you over the age of 21?YesNo

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home Phone *

Cell Phone *

Email Address

Driver's License Number

Has your driver's license been suspended or revoked?YesNo

If yes, please explain:

Are you a U.S. citizen?YesNo

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

Have you lived in Missouri for the past five (5) years?YesNo

If No, please list states:

General Information

Have you ever been convicted of a crime, found guilty, plead guilty and/or pleas of nolo contendere except for minor traffic violations?YesNo

Are you able to perform the essential job functions of the position for which you are applying with or without reasonable accommodation?YesNo

If yes, please explain:

EDUCATION & TRAINING

Last Grade Completed

DegreeMastersDoctorate

Name & Address of School

Major Course Studied

Graduated or Degree (Y or N)

Average Grade

Name & Address of School

Major Course Studied

Average Grade

Graduated or Degree (Y or N)

References

Please List Three Professional references.

Name

Relationship

Phone

Email Address

Name

Relationship

Phone

Email Address

Name

Relationship

Phone

Email Address

Employment History

Company

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

Start Date

End Date

Reason for Leaving

May we contact your previous supervisor for a reference?YesNo

Company

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

Start Date

End Date

Reason for Leaving

May we contact your previous supervisor for a reference?YesNo

Company

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

Start Date

End Date

Reason for Leaving

May we contact your previous supervisor for a reference?YesNo

Position applying for, be specific:

Salary Requirements

Choose FrequencyPer HourPer Month

READ CAREFULLY

I certify that the information contained in this application is correct to the best of my knowledge and understand that any misstatement or omission of information may result in denial of employment or discharge. I authorized the reference listed above to give you any and all information concerning my previous employment and any pertinent information they may have personal or otherwise, and release all parties from all liability for any damage that may result from furnished same to you

Signature

Date

Background Screening:

Date

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 Agape Healing Hands Home Care, Inc. to conduct a background screening on me. If I am not registered, I will pay fifteen dollars and twenty-five cents ($15.25) registration fee. If there are findings in my screening, and I want to become an employee, I agree to complete a “Good Cause Waiver” Application prior to being hired by Agape Healing Hands Home Care, Inc. Once complete, Agape Healing Hands Home Care, Inc. will receive a report from the Family Care Safety 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.
Pre-Employment Criminal Record Check
 All applicants are required to obtain a criminal background check which is conditions of employment.
Family Care Safety Register (FCSR)
 The FCSR will be checked four times a year.

Are you registered with the Family Care Safety Registry?YesNo

Have you applied for a Good Cause Waiver?YesNo

e-Verify
 Agape Healing Hands Home Care, Inc. is required by the Department of Homeland Security to verify employment eligibility for all newly hired employees regardless of citizenship.
Employee Disqualification List (EDL)
o The EDL maintained by the Department of Health and Senior Services is a listing of individuals who have been determined to have:
o Are you listed on the Employee Disqualification List? ☐Yes ☐ No (verification will be performed)
o Abused or neglected a resident, patient, client, or consumer;
o Misappropriated funds or property belonging to a resident, patient, client, or consumer; or
o Falsified documentation verifying delivery of services to an CDS client or consumer
o The EDL will be check four times a year
Office of Inspector General (OIG)
 The Department of Health and Senior Services requires Agape Healing Hands Home Care, Inc. to run this report on each employee monthly.
Agape Healing Hands Home Care, Inc. can employ no applicant until they pass a screening of the Employee Disqualification List (EDL) and until Agape Healing Hands Home Care, Inc. has obtained a clean background check on the application from the Family Care Safety Registry (FCSR). Anyone listed on the EDL or FCSR will not, under any circumstances, be employed by Agape Healing Hands Home Care, Inc. If hired, the attendant will have a copy of the background check and EDL placed in their application file. If any listings appear on either of these background checks, the attendant will no longer be able to be employed by Agape Healing Hands Home Care, Inc.

Background Screening Application:

Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone (Home)

Phone (Cell)

Please disclose all aliases and social security #’s used by you the applicant:

Signature Authorization:

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 Agape Healing Hands Home Care, Inc. to verify my employment eligibility through e-Verify, OIG, FCSR, EDL, closed record check and criminal record check.

Applicant Signature

Date