Join Our TeamProviding Care with Compassion and Dignity! Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Are you at least 18 years of age? * Yes No Are you legally authorized to work in this country? * Yes No Will you now or in the future require sponsorship for employment visa status (e.g., H1B visa status)? * Yes No Have you ever been convicted of a felony? * Yes No Have you ever been convicted of Medicare or Medicaid fraud? * Yes No If selected for employment are you willing to submit to a Pre-Employment Drug Screening Test? * Yes No Do you currently hold any certifications or licenses? * Yes No What Position are you applying for? * HHA (Home Health Aide) CNA (Certified Nurse's Assistant) Other Available Start Date * MM DD YYYY What is your desired pay (per hour)? * $ Employment Desired * Full Time Part Time Per-diem Are you willing to travel 30 minutes or less 30 minutes to an hour Shift Availability Monday * Please select the box or boxes that reflect your availability. Day Shift (8 am - 4 pm) Evening Shift (4 pm - Midnight) Overnight Shift (Midnight - 8 am) Not Available Tuesday * Please select the box or boxes that reflect your availability. Day Shift (8 am - 4 pm) Evening Shift (4 pm - Midnight) Overnight Shift (Midnight - 8 am) Not Available Wednesday * Please select the box or boxes that reflect your availability. Day Shift (8 am - 4 pm) Evening Shift (4 pm - Midnight) Overnight Shift (Midnight - 8 am) Not Available Thursday * Please select the box or boxes that reflect your availability. Day Shift (8 am - 4 pm) Evening Shift (4 pm - Midnight) Overnight Shift (Midnight - 8 am) Not Available Friday * Please select the box or boxes that reflect your availability. Day Shift (8 am - 4 pm) Evening Shift (4 pm - Midnight) Overnight Shift (Midnight - 8 am) Not Available Saturday * Please select the box or boxes that reflect your availability. Day Shift (8 am - 4 pm) Evening Shift (4 pm - Midnight) Overnight Shift (Midnight - 8 am) Not Available Sunday * Please select the box or boxes that reflect your availability. Day Shift (8 am - 4 pm) Evening Shift (4 pm - Midnight) Overnight Shift (Midnight - 8 am) Not Available Do you drive? * Yes No Do you have a valid driver's license? * Yes No Do you own a car? * Yes No References * Please list at least 3 references Are you willing to provide service to a client with a pet? * Yes No Do you smoke? * Yes No EEO Information Voluntary Self-Identification of Gender, Race, and Ethnicity Why are we asking you to complete this form? Agape Care Solutions is subject to certain government record-keeping and reporting requirements related to civil rights laws and regulations. To comply with these requirements and ensure equal employment opportunities, we invite you to voluntarily self-identify your gender, race, and ethnicity. Providing this information is completely voluntary. Your decision to complete or not complete this form will not affect your opportunity for employment or the terms and conditions of your employment. If you choose not to provide this information, you may select "Prefer not to identify." The information you provide will be kept confidential and used only in accordance with applicable laws, executive orders, and regulations. When reported, the data will not identify any specific individual. Explanation of Categories Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) A person having origins in any of the Black racial groups of Africa. Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including but not limited to Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaskan Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America) who maintains tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Two or More Races (Not Hispanic or Latino) A person who identifies with more than one of the above racial categories. Your participation is voluntary, completion of this form is optional. Your decision to provide or withhold this information will not impact your employment or hiring process in any way. Your response will remain confidential and will be used only to comply with federal reporting requirements and to support equal opportunity initiatives. Agape Care Solutions values diversity and is proud to be an equal opportunity employer. Gender: * Female Male Prefer not to identify Race / Ethnicity: Hispanic or Latino White Black/African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Two or more races Prefer not to identify Voluntary Self-Identification of Disability Why are we asking you to complete this form? At Agape Care Solutions, we are committed to providing equal employment opportunities to all qualified individuals, including those with disabilities. To help us evaluate how well we are supporting this commitment, we invite you to voluntarily self-identify if you have a disability or have ever had a disability. Completing this form is voluntary, but we encourage you to participate. If you are applying for a job, your response will remain confidential and will not be used against you in any way. If you are currently employed with us, your answer will not affect your job status or opportunities. Since disabilities can develop at any time, we may ask our employees to update this information periodically. You can self-identify at any time without concern for negative consequences, even if you previously chose not to disclose a disability. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity or if you have a history or record of such an impairment or condition. Examples of disabilities include, but are not limited to: Blindness Deafness Cancer Diabetes Epilepsy Autism Cerebral palsy HIV/AIDS Schizophrenia Muscular dystrophy Bipolar disorder Major depression Multiple sclerosis (MS) Missing limbs or partially missing limbs Post-traumatic stress disorder (PTSD) Obsessive-compulsive disorder (OCD) Impairments requiring the use of a wheelchair Intellectual disability Reasonable Accommodation Notice We are committed to providing reasonable accommodations to qualified individuals with disabilities. If you need an accommodation to apply for a job or to perform your job duties, please let us know. Examples of reasonable accommodations include: Adjusting the application process or work procedures. Providing documents in an alternate format. Offering a sign language interpreter. Providing specialized equipment. This information is being collected in compliance with Section 503 of the Rehabilitation Act of 1973 and will be kept confidential as required by law. For more information about equal employment obligations, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. According to the Paperwork Reduction Act of 1995, you are not required to respond to this collection of information unless it includes a valid OMB control number. Please select one of the options below: * Yes, I have a disability (or previously had a disability) No, I don't have a disability I prefer not to answer Voluntary Self-Identification of Veteran Status Why are we asking you to complete this form? At Agape Care Solutions, we are committed to supporting veterans and ensuring equal employment opportunities for all qualified individuals, including those who have served in the military. To help us meet our commitments and comply with federal regulations, we invite you to voluntarily identify your veteran status. Providing this information is voluntary and will not affect your opportunity for employment or the terms and conditions of your employment. Your response will be kept confidential and used only to support our veteran programs and comply with applicable regulations. If you choose not to answer, it will not impact your employment or hiring process. Explanation of Veteran Categories Armed Forces Service Medal Veteran Any veteran who, while serving on active duty in the U.S. military (ground, naval, or air service), participated in a military operation for which an Armed Forces Service Medal was awarded under Executive Order 12985 (61 FR 1209). Active Duty Wartime or Campaign Badge Veteran Any veteran who served on active duty in the U.S. military (ground, naval, or air service) during a war or in a campaign or expedition for which a campaign badge has been authorized by the Department of Defense. Recently Separated Veteran Any veteran who was discharged or released from active duty in the U.S. military (ground, naval, or air service) within the last three years. If this applies to you, please provide your date of discharge or release. Disabled Veteran One of the following: A veteran of the U.S. military (ground, naval, or air service) who is entitled to compensation (or would be entitled to compensation if not for receiving military retired pay) under laws administered by the Secretary of Veterans Affairs. A veteran discharged or released from active duty due to a service-connected disability. Your participation is voluntary Completion of this form is optional. If you choose not to disclose your veteran status, you may select “Prefer Not to Identify.” Your response will remain confidential and used only to comply with federal requirements and support veteran programs. Agape Care Solutions values the dedication and sacrifices of our veterans and is proud to be an equal opportunity employer. Veteran Category: * Prefer Not to Identify Armed Forces Service Medal Veteran Active Duty Wartime or Campaign Badge Veteran Recently Separated Veteran Disabled Veteran Non-Veteran Applicant Certification and Authorization I affirm that the information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation, omission, or falsification of facts may result in the denial of my application or, if employed, the termination of my employment with Agape Care Solutions. I authorize Agape Care Solutions and its designated representatives to verify the information provided, including but not limited to my criminal background and driving record. I also authorize any individuals, educational institutions, past employers, and law enforcement agencies to release information concerning my background. I release all such parties from any and all liability arising from the disclosure of this information. I understand that Agape Care Solutions is committed to maintaining a drug-free workplace and that pre-employment and ongoing drug screening may be required. I consent to such testing as a condition of employment. I acknowledge that this application does not constitute a contract of employment. I understand that if I am hired, my employment with Agape Care Solutions will be on an at-will basis, meaning that either I or the company may terminate the employment relationship at any time, with or without cause or notice. Any modifications to this at-will employment agreement must be made in writing and signed by an authorized representative of the company. Finally, I understand that due to the nature of home care services, hours of work may vary and cannot be guaranteed. By signing below, I confirm that I have read, understood, and agree to the terms and conditions stated above Acknowledgment * By selecting an option below, I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Applicant Certification and Authorization above. I acknowledge and agree I do not acknowledge or agree Thank you!
