Employment-Application | Bilingual In Home

First Name *

Middle Name

Last Name *

Phone *

Email Address

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Emergency Contact Info

Contact Name

Relationship

Contact Phone

School 1

School Name

Years Attended

Degree Received

Major

School 2

School Name

Years Attended

Degree Received

Major

School 3

School Name

Years Attended

Degree Received

Major

Work ExperiencePlease list prior work, military, and volunteer (unpaid) experience. List from most recent.

Work 1

Name of Employer

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Starting Date

End Date

Duties Performed

Position Title

Rate of Pay

Supervisor's Name

May we contact?

Work 2

Name of Employer

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Starting Date

End Date

Duties Performed

Position Title

Rate of Pay

Supervisor's Name

May we contact?

Work 3

Name of Employer

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Starting Date

End Date

Duties Performed

Position Title

Rate of Pay

Supervisor's Name

May we contact?

ReferencesEmployers are mandated to collect two professional or three personal non-related references. Your application will not be processed until required information is obtained.

Reference 1

Name

Relationship

Phone

How long have you known this person?

Reference 2

Name

Relationship

Phone

How long have you known this person?

Reference 2

Name

Relationship

Phone

How long have you known this person?

Have you been previously employed with Bilingual In-Home Assistant Services? *

List all languages you speak fluently *

Do you have reliable transportation? *

Have you been a resident of Missouri for five years or more? *

Are you able to help with bed-bound patients? *

Are you able to lift 25lbs? *

Are you authorized to work in the US? *

Are you subject to any non-compete agreement that may limit your ability to work with us? *

Do you have at least six months of paid work experience as an agency homemaker, nurse, aide, maid, or household worker? *

Do you have at least one year of experience paid or unpaid in caring for children or for sick or aged individuals? *

Have you completed formal training in nursing arts or as a nurse/home health aide? *

Law requires we collect information on prior convictions.

Have you been convicted of a misdemeanor within the last five years? *

Have you ever been convicted of a Felony? *

Have you ever been convicted of a Felony involving dishonesty or a breach of trust? *

Have you ever been listed in the Employee Disqualification List (EDL) maintained by the Department of Health and Senior Services? *

Have you ever been determined to have abused or neglected a resident, patient, client, or consumer? *

Have you ever misappropriated funds belonging to a resident, patient, client, or consumer? *

Have you ever falsified documentation verifying delivery of services to an in-home services client or consumer? *

Release & Authorizations

I attest that I am 18 years of age or older . *YesNo

I am able to read and write. *YesNo

I authorize Bilingual In-Home Assistant Services to conduct FCSR, EDL, OIG, E-Verify and any other required background checks and understand that any employment offered to me is conditional upon successful results of my criminal and background checks. I understand that these checks will be performed regularly throughout my employment and I must notify employer immediately upon any changes in my work authorization, criminal history or capacity to perform my duties as a healthcare worker. *YesNo

I will perform my work duties and make my employer fully aware of any outside employment. I attest that the information I provide about my outside employment, is current and true *YesNo

If hired, I agree to comply with all employment policies and procedures. I CERTIFY that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information submitted on this application will constitute grounds for denial or dismissal from employment.

I AUTHORIZE all persons, schools, employers and other organizations mentioned in this application to provide BILINGUAL IN-HOME ASSISTANT SERVICES with any and all information requested by BILINGUAL IN-HOME ASSISTANT SERVICES related to my qualifications for employment. I hereby voluntarily release BILINGUAL IN HOME ASSISTANT SERVICES and any other persons or entities from any and all liability to the provision of such information.

I further understand that any job offer will be contingent upon satisfactory replies to background and reference checks and prior criminal convictions and that information about the content and scope such checks will be furnished to me if I make a written request for such information within a reasonable time.

The employment atBILINGUAL IN-HOME ASSISTANT SERVICES is “at will,”: both the employer and the employee are free to terminate the employment relationship at any time, with or without notice or cause.

I Accept These TermsYesNo

Background Check Authorization

The state of Missouri and federal law requires ongoing verification of employment eligibility. Bilingual In-Home Assistant Services complies with the regulations requirements and performs the following checks prior to hire and during active employment: The FCSR check aims to protect children, senior, and the disabled by providing background information including criminal history records, sex offender registry records, child abuse/neglect records, foster parent licensure records, child care licensure records, employee disqualification list, and employee disqualification registry. The EDL check aims to verify a listing of individuals who have been determined to have: abused or neglected a resident, patient, client, or consumer; misappropriated funds or property belonging to a resident, patient, client, or consumer; or falsified documents verifying delivery of services to an in-home services client or consumer. The OIG check aims to verify individuals and entities who have been excluded from federally funded healthcare programs and on the List of Excluded Individuals and Entities. The E-Verify is performed for employment eligibility verification. Bilingual In-Home Assistant Services ensures equal employment opportunities and an environment that values diversity for work-authorized individuals. State and FBI Background Checks are performed to ensure safety of our consumers and requires the applicant to submit to the local police department.

I authorize Bilingual In-Home Assistant Services to conduct aforementioned background checks and understand that any employment offered to me is conditional upon successful results of my criminal and background checks. I understand that these checks will be performed regularly throughout my employment and I must notify employer immediately upon any changes in my work authorization, criminal history or capacity to perform my duties as a healthcare worker.

Signature Required *