Caregiver/Provider Application Form

Home Caring LLC is an equal opportunity employer. We will not discriminate and will take affirmative action measures to ensure against discrimination in employment, recruitment, advertisements for employment, compensation, termination, upgrading, promotions, and other conditions of employment against any employee or job applicant on the bases of race, color, gender, national origin, age, religion, creed, disability, veteran’s status, sexual orientation, gender identity or gender expression. However, this does not imply that the applicant will be hired for caregiving services.

Information

Name: *

Social Security #: *

Present Address: *

Cell Phone: *

Home Phone: *

Are you legally able to work in the United States? *

Yes

No

Are you employed now? *

Yes

No

May we contact your present employer? *

Yes

No

If no, Why? *

Applying For

Companion/Caregiver

Years experience: *

Languages

What language(s) other than English do you speak and understand? *

Notify in Case of Emergency

Name: *

Relationship: *

Address: *

Phone: *

Preferences

Does smoking, cats, or dogs bother you? *

Yes

No

Do you smoke? *

Yes

No

Do you prefer working with males or females? *

Males

Females

No Preference

Transportation

Do you drive? *

Yes

No

If yes, Driver’s License No. *

Expires *

How will you get to work: *

Own Car

Dropped Off

Public Transportation

What areas are you willing to travel to for work? *

Schedule Availability

Hourly

Week days

Weekends

Mornings

Afternoons

Please fill in times available below:

Day	From	To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Do you have responsibilities that would limit your availability? *

Yes

No

If yes, Explain: *

Do you limit your annual earnings due to Social Security or other reasons? *

Yes

No

If yes, Explain: *

Please explain anytime you were unavailable for assignments: Type NA if Not Applicable *

Education

Highest level of education completed: *

Name of School: *

Location: *

Courses Taken: *

Date Completed: *

Diploma, Degree or Certification: *

Previous Employers (List last employer first)

Employer	Dates Worked	Salary	Position and Duties	Reason for Leaving
Employer Name: * Address: * Phone No: * Supervisor: *	Dates Worked From: * To: *	Salary Starting: * Ending: *	Position and Duties: *	Reason for Leaving: *

Reference Release Form

I understand that Home Caring will check references, as part of the hiring process, to learn about my work history. I understand that these references will be confidential. I also understand that I will not have access to them. I release Home Caring and all providers of information from any liability as a result of furnishing and receiving this information.

Failure to authorize contact may exclude you from being considered for employment.

I give permission for the representative of Home Caring to contact my current employer for a reference. *

Yes

No

I give permission for the representative of Home Caring to contact my past employers as shown on my job application and those listed below for employment references. *

Yes

No

Other References that may be called

Name:

Title:

Company:

Phone Number:

Name:

Title:

Company:

Phone Number:

Applicant Signature *

Date

NOT APPLICABLE

Home Caring LLC Reference Release Form - First Previous Employer

Applicant’s Authorization

Applicant Name: *

Social Security #: *

Former Employer: *

Dates Employed: *

I consent to and authorize the above named former employer, and its agents and employees, to furnish any reference information concerning me, including achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment, relating to my employment with the former employer. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment. I also herby release the above named former employer, and its agents and employees, from all liability for damages or claims, including but not limited to defamation, interference with contract, or prospective economic advantage and negligence, I have or may have which arise or result from any reference information provided pursuant to this authorization or any attempts to comply with this information.

Applicant Signature *

Date *

NOT APPLICABLE

Home Caring LLC Reference Release Form - Second Previous Employer

Applicant’s Authorization

Applicant Name:

Social Security #:

Former Employer:

Dates Employed:

I consent to and authorize the above named former employer, and its agents and employees, to furnish any reference information concerning me, including achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment, relating to my employment with the former employer. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment. I also herby release the above named former employer, and its agents and employees, from all liability for damages or claims, including but not limited to defamation, interference with contract, or prospective economic advantage and negligence, I have or may have which arise or result from any reference information provided pursuant to this authorization or any attempts to comply with this information.

Applicant Signature

Date

Confidential

Home Caring LLC Background Check Authorization

Applicant Name: *

Social Security #: *

Former Name(s) and Dates Used: *

Current Address: *

At Current Address Since: *

Phone No: *

Drivers License/Texas ID: *

The information contained in this application is correct to the best of my knowledge. I hereby authorize Home Caring LLC and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Home Caring LLC or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. I hereby release Home Caring LLC, the Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

Applicant Signature *

Date *

Confidential

DPS Computerized Criminal History (CCH) Verification

I,

Applicant or Employee Name (Please print) *

acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company.

Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

(This copy must remain on file by your agency. Required for future DPS Audits)

Signature of Applicant or Employee *

Date *

Agency Name (Please Print)

Agency Representative Name (Please Print)

Signature of Agency Representative

Date

Office Use Only

Please: Check and Initial each Applicable Space

CCH Report Printed:

Yes

No

initial

Purpose of CCH:

Empl

Vol/Contractor

initial

Date Printed:

initial

Destroyed Date:

initial

Retain in your files

Employability Consent Form

Name: *

(Please print as listed on social security card and/or TX DL)

DOB: *

SS#: *

Additional Alias Names used if any including maiden name if applicable:

I,

, have had no prior convictions of any of the offenses listed below which would bar or potentially bar employment.

an offense under Chapter 19, Penal Code (criminal homicide);
an offense under Chapter 20, Penal Code (kidnapping and unlawful restraint);
an offense under Section 21.02, Penal Code (continuous sexual abuse of young child or children), or Section 21.11, Penal Code (indecency with a child);
an offense under Section 22.011, Penal Code (sexual assault);
an offense under Section 22.02, Penal Code (aggravated assault);
an offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
an offense under Section 22.041, Penal Code (abandoning or endangering child);
an offense under Section 22.08, Penal Code (aiding suicide);
an offense under Section 25.031, Penal Code (agreement to abduct from custody);
an offense under Section 25.08, Penal Code (sale or purchase of a child);
an offense under Section 28.02, Penal Code (arson);
an offense under Section 29.02, Penal Code (robbery);
an offense under Section 29.03, Penal Code (aggravated robbery);
an offense under Section 21.08, Penal Code (indecent exposure);
an offense under Section 21.12, Penal Code (improper relationship between educator and student);
an offense under Section 21.15, Penal Code (improper photography or visual recording);
an offense under Section 22.05, Penal Code (deadly conduct);
an offense under Section 22.021, Penal Code (aggravated sexual assault);
an offense under Section 22.07, Penal Code (terroristic threat);
an offense under Section 33.021, Penal Code (online solicitation of a minor);
an offense under Section 34.02, Penal Code (money laundering);
an offense under Section 35A.02, Penal Code (Medicaid fraud);
an offense under Section 36.06, Penal Code (obstruction or retaliation);
an offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to non-livestock animals); or
a conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.

A conviction of the following within the last 5 years:

an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;
an offense under Section 30.02, Penal Code (burglary);
an offense under Chapter 31, Penal Code (theft), that is punishable as a felony;
an offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;
an offense under Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;
an offense under Section 37.12, Penal Code (false identification as peace officer); or
an offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).

I understand that the agency will conduct a criminal history search [will include a State of Texas criminal history search], a Texas Employee Misconduct Registry [EMR] search, and a search of the Texas Nurse Aide Registry [NAR]. I understand that I cannot be employed if the criminal history results identify offenses that bar employment or if I am listed as unemployable as a result of the employee misconduct registry search or the nurse aide registry search. I understand that the agency will complete the searches of the EMR and the NAR at least on an annual basis for unlicensed staff with face-to-face client contact. The EMR rules are referenced at Title 40, Part 1, Chapter 93 [RULE§ 93.3] and Chapter 253, Texas Health and Safety Code, Employee Misconduct Registry. I understand the agency reserves the right to conduct a criminal history search and / or searches of the EMR and the NAR at any time for any reason on all staff regardless of whether the staff has direct client contact.

I understand that if the agency believes that a conviction or other criminal history results may bar my employment or may be a contraindication to employment that I can be fingerprinted at my own cost and request that the criminal history results be forwarded to the agency as a way of verifying the accuracy of my criminal history record.

I, the undersigned, hereby authorize this agency to conduct the employability/background screenings as listed above

Applicant Signature *

Date *

210-737-9230

info@homecaringsanantonio.com