EMPLOYMENT INTERESTED IN A CAREER WITH SEVA HOME HEALTHCARE? CONTACT US TODAY! – (816) 429-7468 …or complete the application below SEVA Home Healthcare, Inc. Employment Application An Equal Opportunity EmployerDate DD slash MM slash YYYY SSN # Email Full legal name Present Address Street Address City State / Province / Region ZIP / Postal Code Cell PhoneHome PhonePrevious Address (if current address is less than 5 years) Employment Desired:Position applying for How many hours per week are you available to work? What days and hours are you available? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday hours Tuesday Hours Wednesday hours Thursday hours Friday hours Saturday hours Sunday hours Are you available on weekends and holidays? Yes No If hired, on what dates can you start work? MM slash DD slash YYYY If hired, would you have a reliable means of transportation to and from work? Yes NO Personal InformationHave you ever applied at or worked for SEVA Home Healthcare, Inc. before? Yes NO When Do you have any friends or relatives working for SEVA Home Healthcare, Inc.? Yes NO State name(s) and relationship How were you referred to SEVA Home Healthcare, Inc. ? Are you at least 18 years old? Yes No If hired, can you present evidence of your US citizenship or proof of your legal right to live and work in this country? Yes No Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accomodations? Yes No Describe the functions that you cannot perform?(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subjected to passing a medical examination and or passing skill and agility tests.)Have you ever been found guilty after trial, pleaded guilty, no contest or nolo contendere to a crime (felony or misdemeanor) in any court? Yes No State nature of the crime(s), when and where convicted and disposition of the case?(Note: No applicant will be denied employment sole.ly on the grounds of conviction of a criminal officer. The nature of the offense, the date of the offense, the surrounding circumstances, and the relevance of the offense to the positions(s) applied for may, however, be considered.)Are you currently employed? Yes No If so, may we contact your current employer? Yes No Education, Training and ExperienceHigh SchoolName & Address of School No. of yrs completedYear Graduated Degree/Diploma Collenge/UniversityName & Address of School No. of yrs completedYear Graduated Degree/Diploma Vocational/BusinessName & Address of School No. of yrs completedYear Graduated Degree/Diploma OtherName & Address of School No. of yrs completedYear Graduated Degree/Diploma Some of our clients do not speak English. Do you speak, write or understand any foreign languages? Yes No Which language(s)? Do you have any other experience, training, qualifications or skills, which you feel make you especially suited for work at SEVA Home Healthcare, Inc.? Please Describe below:Are you applying for a professional position: Yes No Are you Certified/Licensed for the job applied for? Yes No Name of certification/Licensure Issuing State Certificate/License number Has your license/certification ever been revoked or suspende? Yes No State reason(s), date of revocation or suspension and date of reinstatementEmployment History List below all present and past employment starting with your most recent employer (last ten years is sufficient). You Must completed this section even if attaching a resume.(1) Name of Employer Telephone No.Type of Business Your Supervisor's Name Street Address City State / Province / Region ZIP / Postal Code Dates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Weekly PayStartingEndingReason for LeavingWant to add more employment history. Yes No (2) Name of Employer Telephone No.Type of Business Your Supervisor's Name Street Address City State / Province / Region ZIP / Postal Code Dates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Weekly PayStartingEndingReason for LeavingI want to add one more employment history. Yes No (3) Name of Employer Telephone No.Type of Business Your Supervisor's Name Street Address City State / Province / Region ZIP / Postal Code Dates of EmploymentFrom MM slash DD slash YYYY To MM slash DD slash YYYY Weekly PayStartingEndingReason for LeavingMay we contact your current and/or previous employer(s) for reference? Yes No Please list employer(s) you do not wish for us to contact Military ServiceHave you obtained any special skills or abilities as the result of service in the military? Yes No Describe belowPersonal Reference List below three persons not related to you who can give a character referenceName First Last TelephoneStreet Address Street Address Occupation No. of Years AcquaintedName First Last TelephoneStreet Address Street Address Occupation No. of Years AcquaintedName First Last TelephoneStreet Address Street Address Occupation No. of Years AcquaintedPlease read carefully, initial each paragraph and sign below: I hereby certify, under penalty of perjury, that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize the SEVA Home Healthcare, Inc. to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose the SEVA Home Healthcare, Inc. any and all letters, reports and other information related to my work records. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the SEVA Home Healthcare, Inc. In addition, I expressly agree and understand that, if employed, my employment, having no specific term,is based upon mutual consent and may be terminated at will, with or without cause or notice, by either party (the company or me). I also understand that this aspect of my employment, which includes the SEVA Home Healthcare, Inc. right to demote or otherwise discipline with or without cause or notice, my not be changed, modified, amended or rescinded except by and individual written agreement signed by both me and the administrator or the SEVA Home Healthcare, Inc. I understand that any offer of employment regarding certain job positions may be conditioned upon satisfactory completion of a medical examination and/or a drug and alcohol screen. I agree to drug and alcohol screen should the SEVA Home Healthcare, Inc. condition my offer of employment upon successful completion of such an examination or screening. I acknowledge that I have read all of the above Statements and that I understand them. In addition, the statements above supersede and replace any prior understandings or discussions I have had with the SEVA Home Healthcare, Inc. and set forth the complete agreement between me and the SEVA Home Healthcare, Inc. regarding these matters. Please type full name below Date MM slash DD slash YYYY Background Screening It is mandatory that all applicants be registered with the Missouri Department of Health and Senior Services Family Care Safety Registry. My signature below provides authorization for SEVA Home Healthcare, Inc. to conduct a background screening on me. If I am not registered I will pay the eleven dollars ($11) registration fee, if there are findings in my screening, and I want to become an employee, I agree to complete a “Good Cause Waiver” Application prior to being hired by SEVA Home Healthcare, Inc. Once complete, SEVA Home Healthcare, Inc. will receive a report from the Family Registry indicating a Good Cause Waiver has been received and a case opened on my behalf. The Department of Health and Senior Services may grant (approve) a “Good Cause Waiver” at their discretion. FCSR The FCSR will be checked four times a year E-Verify SEVA Home Healthcare, Inc. is required by the Department of Homeland Security to verify employment eligibility for all newly hired employees regardless of citizenship. EDL The Employee Disqualification List (EDL) maintained by the Department of Health and Senior Services is a listing or 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 documentation verification delivery of services to an in-home services client or consumer. The EDL will be checked four times a year. No applicant can be employed by SEVA Home Healthcare, Inc. until they pass a screening of the Employee Disqualifications List (EDL) and until SEVA Home Healthcare, Inc. has obtained a clean background check on the applicant from the Family Care Safety Registry (FCSR). Anyone Listed on the EDL will not, under any circumstances, be employed by SEVA Home Healthcare, Inc. If hired, the attendant will have a copy of the background check and EDL placed in their application file. If any new listings appear on either of these background checks, the attendant will no longer be able to be employed by SEVA Home Healthcare, Inc. SIGNATURE AUTHORIZATION: I have read this policy and understand my employment is conditional pounding the outcome of the Missouri Department of Health and Senior Services’ final decision and determination. I also grant permission for you to verify my employment eligibility through E-Verify and EDL. Please type full name below Date MM slash DD slash YYYY BACKGROUND SCREENING APPLICATIONName First Street Address City State / Province / Region ZIP / Postal Code Phone Number (Home)CellSocial Security NoDate of Birth MM slash DD slash YYYY 1. Have you ever used an Alias (first and/or last names other than the name you used in this application)? Yes No List all those names you have ever used (please include all maiden names and all married names.2. Have you ever used any other Social Security Numbers? Yes No List all social security numbers you have ever used.3. Have you ever had any of the following: Criminal convictions, findings of guilt, pleas of guilty and pleas of nolo contendere? (A pleas in a criminal prosecution that without admitting guilt subjects the defendant to conviction but does not preclude denying the truth of the charges in a collateral proceeding) Yes No List all criminal convictions, findings of guilt, and pleas of nolo contendere. Do not list minor traffic offenses, such as speeding tickets and parking tickets.4. Do you give consent to a closed Background Check, Pursuant to Section 610.120 RSMO? Yes No Criminal Background Check Policy and Release Form According to the Missouri regulation (660.317 R.S. Mo.) all employees of SEVA Home Healthcare, Inc. are required to have criminal background checks prior to providing services to our clients. As required by 660.317 RS MO, I authorize SEVA Home Healthcare, Inc. to request a criminal background check as provided for in 43.450 RS MO. If I have not resided in Missouri for the five years immediately preceding my application for employment, I authorize SEVA Home Healthcare, Inc.to request a nationwide criminal background check. I agree the provide SEVA Home Healthcare, Inc. all information necessary to conduct such background checks including, but not limited to, fingerprints, previous names used, previous addresses, previous driver’s licence number, social security number, and date of birth. I consent to SEVA Home Healthcare, Inc. release my criminal history to employee disqualification list information in connection with the clinical portion of my educational program. I do not authorize release of this information for any purpose beyond this action. I release and hold SEVA Home Healthcare, Inc. and the respective officers, directors and employees harmless from any and all liability with respect to the investigation, verification and/or use of any information relevant to my application for employment. According to the Kansas Statute (22-3210) all employees of SEVA Home Healthcare, Inc. are required to have criminal background checks prior to providing services to our clients. As required by Kansas Statute (22-3210) I authorize SEVA Home Healthcare, Inc. to request a criminal background check as provided for in 22-3210. If I have not resided in Kansas for the five years immediately preceding my application for employment, I authorize SEVA Home Healthcare, Inc. to request nationwide criminal background checks. I agree to provide SEVA Home Healthcare, Inc. all information necessary to conduct such background checks including, but not limited to, fingerprints, previous names used, previous addresses, previous driver’s licence number, social security number, and date of birth. I consent to SEVA Home Healthcare, Inc. release my criminal history to employee disqualification list information in connection with the clinical portion of my educational program. I do not authorize release of this information for any purpose beyond this action. I release and hold SEVA Home Healthcare, Inc. and the respective officers, directors and employees harmless from any and all liability with respect to the investigation, verification and/or use of any information relevant to my application for employment. Please type full name below Date MM slash DD slash YYYY APPLICANT MINIMUM QUALIFICATIONS FOR HIREName First Department of Health and Senior Services - Division 15 - Division of Senior and Disability Services - Chapter - Service Standards - 19 CSR 15-7.021 - PAGE 10 (19c) Applicant must fulfill the following minimum requirements for hire as an in-home service aide. I acknowledge that I fulfill the following requirements:All in-home service workers employed by SEVA Home Healthcare, Inc. shall meet the following requirements:(please check both, if true) I acknowledge that I am 18 Years of age or older. I acknowledge that I can read, write and follow directions. I acknowledge that I meet at least one (1) of the following requirements: (check all that apply) I have at least six (6) months paid work experience as an agency homemaker, nurse aide, maid or household worker, or CNA, LPN, or RN I have at least one (1) years experience, paid or unpaid in caring for children or for sick or aged individuals: or I am a certified Nurse Assistant ___ LPN ___ RN Additional Information for consideration:Please type full name below Date MM slash DD slash YYYY
