APPLICATION FOR EMPLOYMENT

Transcription

1 APPLICATION FOR EMPLOYMENT Name Phone ( ) Last First MI Address Street City State Zip Address SSN(optional) Position Desired EDUCATION: Name/Address Last year completed GRADUATED Yes No Degree/Major High School/G.E.D College Grad. School Nursing School Other Application Packet Page 1 of 6

2 EXPERIENCE: (List last four jobs with most current listed first) May we contact your present employer? Y N EMPLOYER & LOCATION JOB TITLE & DUTIES DATES EMPLOYED Start End REASON FOR LEAVING MISCELLANEOUS: 1. Are you legally eligible for employment in the United States? yes no 2. Can you provide your own transportation to and from work? yes no 3. Are you currently in good standing on the MN CNA registry? yes no 4. Do you have any special skills? 5. I authorize your agency to conduct a background study through the Minnesota Department of Human Services and Global HR yes no (If yes, please complete Informed Consent form on the following page) Signature: Date: Application Packet Page 2 of 6

3 JOB SPECIFICS Name Phone Date available : Salary expected Shifts Days Evenings Overnights Live In Approx. Hrs/ week Geographical Location (how many miles are you able to travel for a shift?) Please note the start and end times for each day you are available. Every other weekend availability is mandatory per company policy. Day Start Time End Time Sunday Monday Tuesday Wednesday Thursday Friday Saturday I understand that the above availability is my permanent availability for the first 90 days of employment. Any changes to my availability after 90 days will be communicated, in writing, to the Staffing Manager. Signature: Date: Application Packet Page 3 of 6

4 Informed Consent Form Minnesota Department of Human Services The following person has made an application with Matrix Home Health Care Specialists (dba for Matrix AdvoCare Network) for employment: Name of Applicant: Last First Full Middle Date of Birth: Driver s License # Address I hereby authorize and grant my informed consent to permit you to release to and make available to Matrix Home Health Care Specialists [ Matrix ] and/or its agents and/or representatives data classified as private which concerns me and which may be in your possession, data which has been collected by you as a result of my contacts and associations with you and/or your agents and representatives. The information for which release is authorized includes all data which has been collected, created, received, retained or disseminated in whatever form which in any way relates to my dealings with you or your agency. I understand that the purpose of permitting Matrix and/or its agents and/or representatives to have access to this information is to determine my suitability for employment with that company. I further understand that this information may subsequently be utilized for other purposes relating to my possible employment with the agency, including verification of my records and analysis by consultants to the company who may review my suitability for employment. This authorization shall be valid for a period of one year, but I reserve the right to, at any time prior to that expiration, cancel the written authorization by providing written notice to Matrix and to you of that fact. I further authorize a copy to be as valid as the original. Signature Date Signed Application Packet Page 4 of 6

5 NOTICE AND ACKNOWLEDGMENT [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGMENT] NOTICE REGARDING BACKGROUND INVESTIGATION Employer ( the Company ) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by Global HR Research, 9530 Marketplace Road, Suite 301, Fort Myers, FL 33912, Office: (239) , Toll Free: , website: or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report. New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days. New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request. Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Global HR Research, another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. DATE Current Address: PRINT NAME SIGNATURE OF EMPLOYEE OR PROSPECTIVE EMPLOYEE SOCIAL SECURITY NUMBER Date of Birth (For Background Purposes Only) Drivers License Number State Previous Addresses (Last 7 years): Any other names I have been known by (including maiden name): Application Packet Page 5 of 6

6 MATRIX HOME HEALTH CARE SPECIALISTS REFERENCE FORM Please make three copies of this form to distribute to three Professional references to complete Return completed forms to our office via fax. Name of Applicant Name of Reference Reference Phone Number Relationship to Applicant Phone: Fax Number I give my permission to have reference information. Name of reference complete the following Applicant s Signature Please check the box that best describes the applicant s qualifications based on your experience and opinion. Least Best Comes to work when scheduled and on time. 2. Comes to work appropriately dressed and groomed. 3. Develops healthy relationships with clients & families. 4. Works independently with intermittent RN supervision 5. Knows when to notify RN of issues and concerns. 6. Sets appropriate priorities during workday. 7. Can work as a member of a team. 8. Communicates effectively verbally. 9. Communicates effectively in formal written format. 10. Works with others in discordant situations. 11. Meets commitments and deadlines. 12. Maintains appropriate boundaries with clients/families. 13. Is honest and ethical. Date Would you want this applicant to take care of your parent in his or her home yes no Rationale Please add any comments that would help us understand the strengths and limitations of this applicant. Thank you for your assistance. Please return by fax to 952/ or eengeldinger@matrixadvocare.com Application Packet Page 6 of 6