Careers – lovinginhomecare.net

Employee Application and Background Check Form

Name(Required)

First Last

Phone(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Job Title

1st Day of Services

Vehicular Insurance(Required)

Exp. Date(Required)

Work History/ Activity(Required)

Last five years required/verified (All GAPS must be documented/explained) (Facility must document contacts with employers of 6 months or longer plus the most recent)

Dates (begin-end)

Previous Employer with address/phone number/contact person

Date confirmed information

Person Confirming Information

Facility Contact Notes (Dates of Employment given and other comments)

PERSONAL REFERENCES:

Must list three; one must have known you at least five years (Do not list/duplicate work reference contacts from above or family members) (Facility must document contact with at least two of the three referrences)

Name/Address/Phone Number

Years Known

Facility Contact Notes (Date/Comments)

Signature(Required)

Disclosure and Authorization Form

Background Investigation Questionaire.

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Other Name(s):

Used within the last 7 years. E.g. Maiden, other married names.

Name

Year of Name Change

Name on Driver's License(Required)

First Middle Last

Previous Residential Address (Previous 7 years):(Required)

Street

City

State

Zip Code

Years Resided

Have you been convicted of any criminal offense, either misdemeanor or felony, other than minor traffic violations in the last 7 years?(Required)

Yes

No

Please List approximate date, location of the offense, and details about the offense.(Required)

Are you currently charged or under investigation for any violation of the law other than minor traffic violations?(Required)

Yes

No

Please List approximate date, location of, and details about the offense.(Required)

Disclosure and Authorization

IMPORTANT – PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

LOVING IN-HOME CARE, INC. 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 contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. 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 as a tenant is an investigation into your education and/or employment history conducted by Fowlers’ Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing LOVING IN-HOME CARE, INC. to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and 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.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE 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” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. 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 Fowlers’ Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 another outside organization acting on behalf of LOVING IN-HOME CARE, INC., and/or LOVING IN-HOME CARE, INC. itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

NOTICE: Fowlers’ Profile Links, Inc. requests your Date of Birth solely for the purpose of verifying certain records that may be produced in connection with Fowlers’ Profile Links, Inc. background investigation. It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

Signature

Applicant's Authorization to Release Information / Reference Check

I hereby authorize all past employers and educational institutions to release the information listed below to Loving In-Home Care Inc. (a prospective employer) it’s employees, representatives, and agents for use in determining my qualifications for employment.

You agree to release and verify the following information:

Past Employers
Salary History
Dates of Employment
Positions Held
Responsibilities & Duties Performed
Reason for Leaving
Eligibility for Rehire
Performance
Educational Institutions: Years of attendance, Degree obtained, Transcripts.

In addition to authorizing the release of the information above, I hereby fully waive any rights or claims I have or may have against Loving In-Home Care Inc. (a prospective employer) all past employer and educational institutions and their employee representatives and agents from any and all liability claims or damages that may directly or indirectly result from the use of disclosure or release of any information by any person or party whether such information is favorable or unfavorable to me. I acknowledge that I have read this authorization and fully release liability. It is to my complete understanding and voluntarily signed.

Signature

For the Caregiver

We appreciate you joining our personal support services team. Before you begin providing services, we wanted to spell out what you may expect from our company and in turn our expectations of you.

We are your employer and therefore will be responsible for your:
1. Payroll
2. Taxes and Withholdings
3. Unemployment Taxes
4. Worker’s Compensation Insurance (in the event you are injured while on the jobsite)
Kenney Simpson is your direct supervisor and will be responsible for your supervision, discipline, assignment of duties, and materials/equipment you may need to provide services. You may contact the supervisor at 423-480-1961 (mobile cell number) whenever there is an issue or concern.

Apply Today!

Employee Application and Background Check Form

Disclosure and Authorization Form

Disclosure and Authorization

Applicant's Authorization to Release Information / Reference Check

For the Caregiver