Pyramid Home Health Services - Application for Employment

APPLICATION FOR EMPLOYMENT

We are an equal opportunity / affirmative action employer dedicated to a policy of non-discrimination in employment on the basis of race,

color, age, sex, religion, national origin, disability, veteran status, citizenship or ancestry.

Position(s) Applying For

Date of Application

How did you learn about us?

Advertisement Employment Agency Friend Relative Walk-in Other

Last Name

First Name

Middle Name

Home Address City State Zip

Telephone Number(s)
Home Mobile

Social Security Number

If you are under the age of 18, can you provide required proof of your eligibility to work? YES NO / If yes, give date:

Have you been employed with us before? YES NO / If yes, give date:

Are you currently employed? YES NO / May we contact your present employer? YES NO

Are you prevented from lawfully becoming employed in this Country because of Visa or Immigration status?

YES NO

(Proof of citizenship or immigration status will be required upon employment.)

On what date would you be available for work?

Are you available to work: FULL-TIME PART-TIME TEMPORARY SHIFT WORK

Are you currently on “lay-off” status and subject to recall? YES NO / Can you travel if a job required it? YES NO

Have you ever pleaded guilty or no contest to or been convicted of a misdemeanor or felony in any state? YES NO

If you answered yes, please explain in detail: (Note: A “yes” response will not necessarily prevent employment. Each case and the

circumstances will be considered.)

Are you currently registered with the Family Care Safety Registry?

YES

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

YES

Are you presently employed with another In-Home Service Provider or Home Health Agency? YES NO / If yes, who?

Do you have relative(s)currently employed by us? YES NO / If yes, who?

Are you related either by marriage or blood to any client or patient receiving our services? YES NO / If yes, who?

Have you ever been a resident of or employed in another state? YES NO / If yes, where and what dates?

This job requires consistent, regular and punctual attendance, can you meet this requirement? YES NO

EMPLOYMENT EXPERIENCE

Start with your present or most recent employment. You MUST list at least 5 years employment history.

1) Employer Name

Dates Employed

From To

Describe Work Performed

Address

Telephone Number(s)

Hourly Rate / Wage Amount

Starting Final

Job Title

Reason for Leaving

2) Employer Name

Dates Employed

From To

Describe Work Performed

Address

Telephone Number(s)

Hourly Rate / Wage Amount

Starting Final

Job Title

Reason for Leaving

3) Employer Name

Dates Employed

From To

Describe Work Performed

Address

Telephone Number(s)

Hourly Rate / Wage Amount

Starting Final

Job Title

Reason for Leaving

4) Employer Name

Dates Employed

From To

Describe Work Performed

Address

Telephone Number(s)

Hourly Rate / Wage Amount

Starting Final

Job Title

Reason for leaving

5) Employer Name

Dates Employed

From To

Describe Work Performed

Address

Telephone Number(s)

Hourly Rate / Salary Amount

Starting Final

Job Title

Reason for Leaving

Please explain, in detail, any gaps in your employment history:

EDUCATION

Elementary School

High School

Undergraduate

College / University/Technical

Graduate /

Professional

School Name and Location

Years Completed

4 5 6 7 8

9 10 11 12

1 2 3 4 5

1 2 3 4

Diploma / Degree

Describe course of study

List below description(s) and date(s) any non-paid or volunteer work experience (exclude organizations, the name or character or which would

indicate the race, sex, religion, national origin or disability of its members):

Have you ever had any job-related training in the United States military? YES NO If yes, please describe:

DRIVERS INFORMATION

Are you currently in possession of Automobile Insurance that meets the statutory insurance requirement for the State of Missouri? YES NO

Is this insurance presently enforced? YES NO

Driver’s License Number Issuing State Expiration Date Class

REFERENCES

Give name, address and telephone number of three references who are NOT RELATED TO YOU and are NOT PREVIOUS EMPLOYERS

NAME

ADDRESS

TELEPHONE NUMBER

EMPLOYMENT CONDITIONS

I understand that I will not be considered an employee of Pyramid Home Health Services until the following conditions are met:

References are successfully contacted with positive results.

All orientation and on-the-job training are successfully completed.

All applicable background checks are completed showing no negative history.

Any falsification or material omission of an application for employment will be considered grounds for immediate dismissal.

I understand that if I am hired, at any time during my employment, I become related to any client or patient of ours either by

marriage or blood, I am required to inform my Supervisor immediately.

I further understand that after the above items have been successfully completed, I will be considered an “employee at will”

and my employment may be terminated at any time for any reason.

________________________________________________________________________ ____________________________________

Applicant Signature Date

________________________________________________________________________ ____________________________________

Printed Name Supervisor