Job Selection Job That You Are Applying For (Select only one) * Your Contact Information Name *
* Primary Phone * Cell Phone (If different from your Primary Phone) Email *
We will never sell or disclose your email address to anyone.
Can you, after employment, submit verification of your legal right to work in the U.S.? * Education High School High School Name City State College/University College/University Name City State Degree Professional/Tech School Professional/Tech School Name City State Degree or Major RN/LVN/CNA/CHHA License, Home Care Aide Registration (if applicable) *
You can add more licenses / certifications by pressing the "+" button.
Years of Experience
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Type of Experience Employment Information How did you hear about Choice Home Care?
Please list newspaper name, search engine, referral's name, etc.
If a current Choice Home Care employee referred you, please enter his/her complete name Can you, with or without reasonable accomodation, fully and safely perform the essential duties of the position for which you are applying? * Employment History (please start with current/most recent employer and account for the past 5 years. Include supervisors’ names.) *
You can add more previous employers by pressing the "+" button.
May we contact your current employer? * Attachments or Upload Data Resume Upload (optional) Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf.
If you have a resume you'd like to attach, please do so here. This is not required.
Equal Employment Opportunity Employer
Choice Home Care is committed to a policy of equal employment opportunity for all applicants and employees. Choice Home Care prohibits discrimination against qualified applicants or employees because of race, color, religion, sex, gender identity, pregnancy, national origin, ancestry, citizenship, age, marital status, physical disability, mental disability, medical condition, genetic characteristics, sexual orientation, or any other characteristic protected by state or federal law, and any information furnished on this application will not be used for any purpose prohibited by law.
Accuracy of Information/Background Check
I hereby certify that the information is this application is correct and compete to the best of my knowledge. I understand that falsification or omission of any material information on this application, in the interviewing process or in my resume, or failure to pass a physical examination, may be sufficient cause for immediate termination if I have already received an offer of employment. I understand that this application will no longer be active or receive further consideration once the position for which I am applying has been filled, or if I am employed but do not actively work for Choice Home Care for a period of six months or more.
I agree to have any of the statements herein as well as my background investigated by Choice Home Care or its agents. This authorization shall become effective immediately and shall remain in effect for a period of twelve months after the date of signing this authorization. I understand that the background investigation may include, but is not limited to, reviewing my education, employment history, any public records, and personal references, whether through a search of my Social Security number, name, or other identifying information. In reviewing my employment history, I understand that Choice Home Care may contact any or all of my listed previous employers, and I consent to Choice Home Care doing so. In consideration for reviewing my application and other related information, I hereby waive and release Choice Home Care, its employees and agents, and all other entities and persons from any claims I might have, including defamation and invasion of privacy, arising out of any verbal or written inquires and/or any verbal or written responses related to investigation of my background as well as the use or disclosure of such information. I understand that a photocopy of this authorization is to be considered as valid as the original. EMPLOYMENT “AT WILL” DECLARATION
I agree that if employed, I will abide by all policies and procedures established by the Company. I acknowledge that the Company reserves the right to amend or modify any of its handbooks, policies and procedures at any time and without prior notice. I understand that my employment is “at will”, that I may resign at any time, that the Company may terminate my employment at any time, with or without cause, and that no employee or other representative of the Company has the authority to make an agreement contrary to the foregoing unless it is in writing and signed by the Company President. This constitutes my entire agreement with the Company with regard to the matters set forth in this paragraph.
I understand that Choice Home Care is not an employment agency and that the services it renders is made possible only by a substantial investment in the hiring process for a large staff. As a condition of employment, I agree not to solicit any client or patient for employment that I am assigned, from this date and for a period of 270 days from the last date employed by Choice Home Care. In the event this agreement is violated, I acknowledge it would be difficult to ascertain the precise amount of damages that Choice Home Care would suffer. Therefore, I agree that I will be obligated to pay Choice Home Care $5000.00 in liquidated damages.
CONFIDENTIALITY/ HIPAA AGREEMENT
I agree to maintain confidentiality of all patient information including, but not limited to, names and addresses of clients and referral sources, patient medical condition and course of treatment, rates, etc.; and I understand that my failure to do so may result in disciplinary action up to and including discharge. I also agree to follow the rules and regulations set forth by the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act) which helps ensure that all medical records, medical billing, and patient accounts, both printed and electronic, meet certain consistent standards with regard to documentation, handling and privacy.
MEDICAL PROVIDER NETWORK (MPN)
California law requires us to provide medical treatment in the event you are injured at work. Choice Home Care will provide this care by using a Medical Provider Network (MPN). I am aware that I must immediately notify Choice Home Care should I require treatment. Additional information regarding the MPN is available on the employee website: http://www.choicehmc.com
AUTHORIZATION TO CORRECT FOR PAYROLL ERRORS
Recognizing that payroll errors may occur for a number of reasons (e.g. illegible timecards, misidentification of employee name or number, keystroke errors), if I am employed, I authorize Choice Home Care to withhold pay in order to correct for any payroll error that may have resulted in my overpayment.
AUTHORIZATION FOR RELEASE OF INFORMATION
In connection with my application for employment/promotion/tenancy/care provider, including any contract for services, with you; I understand that a consumer report that may contain public information may be requested from TrustPointe, Inc.I authorize, without reservation, any party or agency by TrustPointe, Inc. or one of its agents to furnish above mentioned information.I have a right to make a request to TrustPointe, Inc., upon proper identification, of the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me, which TrustPointe, Inc. has previously furnished within the two-year periods preceding my request.Residents of California, Maryland, Minnesota, and Oklahoma only; you have the right to receive a copy of your consumer report.
I would like a copy of my report: APPLICANT VERIFICATION DATA Other Names Used
In order to process your application; please provide the following information. Include your exact legal name and any other name(s) you may have used in the last seven (07) years.
Past Residence Data* *
Applicants must provide city and state information for residence covering a period of seven (07) years. Begin with your most current address. If you are not sure of the address, include the city and zip.
AGREEMENT TO PROVIDE SOCIAL SECURITY NUMBER
Should Choice Home Care decide to consider me for employment, I agree to provide my social security number to Choice Home Care upon request for the Criminal Background Check.