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Phc Employment Application Kansas

1. I have been informed of and agree to a complete disclosure of all criminal convictions, finding of guilt, pleas of guilty, and pleas of nolo contendere, except minor traffic violations. Certain offenses may prohibit employment with our company. We will conduct a thorough criminal background check.(Required)

I understand and agree

2. Must be 18 years of age at the time of completing the application; you will need to submit a valid copy of your Driver’s license with picture.(Required)

I understand and agree

3. There are specific functions and requirements of the job; including physical capability inherent in care-giving positions (see job description.)(Required)

I understand and agree

4. A workers’ compensation records search and medical review will be conducted.(Required)

I understand and agree

5. I have been informed and agree that Phoenix Home Care may conduct drug screenings. If you are using illegal drugs of any sort we are unable to hire you.(Required)

I understand and agree

6. We are unable to hire anyone who has been placed on the Kansas Central Registry or the Kansas Nurse Aide Registry for Adult/Child Abuse and Neglect. Complete disclosure, if listed on the registry, is required.(Required)

I understand and agree

7. In order to participate as a Nurse Aide, you must be listed on the Kansas Nurse Aide Registry.(Required)

I understand and agree

8. A minimum of two satisfactory reference checks will be required for employment.(Required)

I understand and agree

9. Through the use of cutting edge technology our Personal Care Attendants’ activities are monitored throughout the workday. You will be required to clock in and out (using the client’s phone) while providing home care services.(Required)

I understand and agree

10. Any job offer is conditional upon satisfactory reference and background checks and completion of a medical review and successfully completing a physical test given at orientation that is based on the job description.(Required)

I understand and agree

11. I agree to a pre-employment criminal record check that will include, but isn’t limited to, the Kansas Bureau of Investigation (KBI).(Required)

I understand and agree

By entering my name and today’s date in the following fields, I agree that this will be considered as my legal signature.(Required)

Your Name

Today's Date

Acknowledgement: To the best of my knowledge the above requirements do not pose a problem with my continuing to pursue employment with Phoenix Home Care.(Required)

I agree

Your Information

Name(Required)

First Middle Last

County of Residence(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Phone

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you a U.S. citizen or legal alien authorized to work in the U.S.?(Required)

If no, please explain

How did you learn about our company?(Required)

Name of Employee

What other?

Have you ever plead guilty, been convicted of a crime, received a suspended imposition of sentence (SIS) or suspended execution of sentence (SES)?(Required)

If yes, please explain

Have you ever applied or been employed by Phoenix Home Care previously?(Required)

If yes, when?

If you have been known or worked by another name, please indicate:

Upon reviewing the position job requirements, are there any reasons why you would NOT be able to perform the essential functions?(Required)

If yes, please explain

Licensure:

Please complete the following for each professional license that you hold:

Type of Licensure #1

State of Licensure

Certificate/License #

Expiration Date

MM slash DD slash YYYY

Type of Licensure #2

State of Licensure

Certificate/License #

Expiration Date

MM slash DD slash YYYY

Education

Highest grade completed(Required)

Schools, Colleges or Universities

Name of Institution

Degree, Diploma or Certificate

No of Years

Did you Graduate?

List any schools, colleges or universities you have attended below:

Employment History

Please list your last three employers below, starting with your most recent or current employer. Please DO NOT leave any blanks incomplete.

Employer Name (#1)(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title(Required)

Description of Duties(Required)

Supervisor Name(Required)

May we contact?(Required)

Phone(Required)

Employment Dates(Required)

Employed from

Employed to

Reason for Leaving(Required)

Employer Name (#2)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Description of Duties

Supervisor Name

May we contact?

Phone

Employment Dates

Employed from

Employed to

Reason for Leaving

Employer Name (#3)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Description of Duties

Supervisor Name

May we contact?

Phone

Employment Dates

Employed from

Employed to

Reason for Leaving

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