* = Required Information

APPLICANT INFORMATION


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Availability


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If you are offered a position working specific hours, you are required to continue working those hours for a minimum of 90 days. If you do not fulfill this 90 day obligation, it could lead to an immediate termination from the company.


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PAST EMPLOYMENT: MOST CURRENT EMPLOYER FIRST

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Laws Pertaining to Hiring

The law prohibits home health agencies from hiring any individual convicted of the following:

  • Arson
  • Murder
  • Robbery
  • Pandering
  • Obscenity Offences
  • Assaults and bodily wounding
  • Abuse and neglect of children
  • Abduction for immoral purposes
  • Taking indecent liberties with children
  • Crimes against nature involving children
  • Abuse and neglect of an adult or incapacitated adult
  • Failure to secure medical attention for an injured child
  • Sexual Assault

However, applicant convicted of one misdemeanor crime not involving abuse or neglect or moral turpitude may be hired provided five years have elapsed since the conviction. Any person making a false statement on this form regarding any criminal offense shall be guilty upon conviction of a class 1 misdemeanor. Further dissemination of the information provided on this form is prohibited other than to a federal or state authority or court as may be required to comply with an expressed requirement of law for such further dissemination.

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APPLICATION CERTIFICATION AGREEMENT: PLEASE READ CAREFULLY

I certify that the statements on this application are true and correct to the best of my knowledge and belief and I hereby grant HOME HEALTH Connection permission to verify such answers. I understand that any false statement on this application may be considered sufficient cause for rejection of this application or for dismissal if such false statement is discovered subsequent to my employment. I authorize HOME HEALTH CONNECTION to contact my prior employers and the educational institutions listed on this application. By my signature, I authorize those individuals and institutions to release all records regarding me, and to discuss my education and employment history with HOME HEALTH CONNECTION and they are released from all liability in connection with any such disclosures. I understand that I must complete this application fully in order to be considered for the position for which I am applying. If I accept employment with HOME HEALTH CONNECTION, I understand that my employment may be terminated at any time, at will of either HOME HEALTH CONNECTION or me, with or without notice. I further understand that I will be subject to the policies and procedures of HOME HEALTH CONNECTION during the period of my employment and agree to abide by them.

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