UNIQUE IN-HOME HEALTH CARE LLC
EMPLOYMENT APPLICATION
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Note: Applications will not be processed unless properly completed.
I want to (select one):
Work for a specific person
Be referred to others
Please Print
NAME: __________________________________ SOCIAL SECURITY #:___________________ D.O.B._________
PHYSICAL ADDRESS: ___________________________________________________________________________
CITY:__________________________________________
STATE: _________
ZIP: _____________
TELEPHONE: ____________________________________ CELL/ALTERNATE #: ___________________________
Can you verify that you meet the following qualifications: Are you at least 18 years of age; able to meet the
physical and mental demands required to perform specific tasks of the consumer; agree to main confidentiality;
be emotionally mature and dependable; be able to handle emergency situations; and are not the consumers
spouse? YES NO
Have you lived in Missouri for the past 5 years?
YES
NO
If NO, list State: ________________
How did you learn of this position? ____________________________________________
Do you smoke?
YES
NO
Is there any reason why you would not be able to perform job duties? YES
NO If Yes, please
explain: ________________________________________________________________________________
BACKGROUND
(A background screening via the FCSR must be performed prior to the first day of employment)
Have you ever been charged with an offense other than a minor traffic violation?
YES
NO
Please disclose all criminal convictions, findings of guilt, pleas of guilt, and pleas of nolo contendere or provide a
statement that there is no record of such background. Failure to disclose any criminal information is a violation
of the law. All convictions will be identified by the FCSR, including convictions more than 10 years ago. If the
answer is no, indicate with an N/A.
Have you used any alias or different SSN? YES
NO If yes, please list below:
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you consent to a pre-employment Criminal record check?
Do you consent to a closed record check?
YES
NO
YES
NO
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YES
NO
Are you registered with the Family Care Safety Registry?
Have you applied for a Good Cause Waiver?
NO
Do you have a valid Drivers License? YES
Do have a skilled license?
YES
YES
NO
If Yes, when?___________________________
If Yes, what type? _____________________________________
NO
Do you have transportation?
YES
NO
Have you ever worked with persons with physical/cognitive disabilities? YES
NO If Yes, please
explain:_____________________________________________________________________________________
___________________________________________________________________________________________
PREFERENCES AND AVAILABILITY (Please be specific and list days and hours available)
Do you prefer working:
SUNDAY
Males
MONDAY
Females
Either
TUESDAY
WEDNESDAY THURSDAY
FRIDAY
SATURDAY
AM
PM
Please check the following duties that you are willing and able to perform on a daily basis:
Dressing
Feeding
Showering
Toilet Routine Transfers
Meal Preparation
Errands/Shopping Laundry Cleaning Homework/Correspondence
REFERENCES (Provide at least three personal references NOT related to you )
Name: ______________________________________
Relationship: __________________________
Address: _____________________________________
Telephone: ____________________________
Name: ______________________________________
Relationship: __________________________
Address: _____________________________________
Telephone: ____________________________
Name: ______________________________________
Relationship: __________________________
Address: _____________________________________
Telephone: ____________________________
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EMPLOYMENT HISTORY (Please list most recent first)
Company/Business Name: ___________________________________ Supervisor:_________________________
Dates Employed: _______ to _______
Position Held:___________________________________________
Telephone Contact #: ____________________________________
Eligible for re-hire?
YES
NO
Duties: ____________________________________________________________________________________
Reason for leaving: __________________________________ May we contact this employer?
YES
NO
Company/Business Name: ___________________________________ Supervisor:_________________________
Dates Employed: _______ to _______
Position Held:___________________________________________
Telephone Contact #: ____________________________________
Eligible for re-hire?
YES
NO
Duties: ____________________________________________________________________________________
Reason for leaving: __________________________________ May we contact this employer?
YES
NO
Company/Business Name: ___________________________________ Supervisor:_________________________
Dates Employed: _______ to _______
Position Held:___________________________________________
Telephone Contact #: ____________________________________
Eligible for re-hire?
YES
NO
Duties: ____________________________________________________________________________________
Reason for leaving: __________________________________ May we contact this employer?
YES
NO
I certify that the answers given herein are true and complete to the best of my knowledge and I hereby consent
and grant permission for a background screening via the FCSR to be performed for employment purposes.
MILITARY RECORD:
Branch of Service ________________________________ Discharge Date:___________ Rank: ______________
Have you ever been convicted of any criminal convictions, findings of guilt or pleas of guilt?
YES
NO
Pleas of nolo contendere, except minor traffic violations? YES
NO If Yes, please explain. (You must
disclose all criminal convictions)_________________________________________________________________
___________________________________________________________________________________________
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AUTHORIZATION:
I know and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I consent to and authorize investigation of all statements contained herein and the references and employers
listed to disclose to you any and all information concerning my previous employment and any pertinent
information that they may have, personal or otherwise and release Unique In-Home Health Care, LLC from
liability for any damage that my result from utilization of such information.
I also understand and agree that no representative of Unique In-Home Health Care, LLC has any authority to
enter into an agreement for employment for any specified period of time, or to make any agreement contrary to
the foregoing, unless it is in writing and signed by an authorized agency representative.
____________________________________________
Signature of Applicant:
________________________________
Date:
FOR VENDOR PURPOSES ONLY: This applicant is ______ eligible or _____ineligible for employment
according to the regulations and the FCSR background screening.
Screening performed by: _______________________________________________________________
Confirmation #: _______________________________ Results:_______________________________
