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Professional / Personal References (Must Complete)

Persons who can furnish information about job performance or personal information about you.

Skill Questions

1) Are you Bilingual? If so, please specify what languages you speak *

General Questions

1) Are you legally eligible for employment in the United States? *

2) Available to work full-time/ part-time? *

3) What days and hours are you available to work? Please see answer example format: Mondays from ___ am / pm to _ am / pm *

4) How did you learn about this company and position? *

5) For your previous answer, please specify the following details 1. Job advertisement (identify publication or other media): 2. Employee referral (identify employee): 3. Other (please specify): *

6) Have you previously worked at our company? *

7) If yes, under what conditions did you leave employment before? Answer N/A if not applicable *

8) Do you have a reliable mode of transportation? *

9) When are you available to start? *

10) I certify that all information I have supplied on this form is correct to the best of my knowledge. I understand that omissions or providing deliberate misinformation will disqualify my application and, if hired, would serve as grounds for dismissal. *

11) I give consent to A DAUGHTERS LOVE PRIVATE HOME CARE LLC to contact the employers listed on this form for my employment references. I authorize these individuals to provide truthful information regarding my employment and previous work experience. In doing so, I waive liability against the employers and individuals contacted as my references, provided the information they supply is honest, factual and given without malice. *

OIG/LEIE Background Checks

POLICY

We comply with licensure requirements regarding criminal history record checks, the OIG for employees, subcontractors, and volunteers.

PROCEDURE

1. Inform the individual who applies for employment that the agency is required to conduct a background check
2. Review the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General, and the LEIE maintained by the HHS Office of Inspector General:
   • before hiring an applicant for employment or contracting with a potential subcontractor; and
   • at least monthly, for each employee and subcontractor.
3. Not employ an applicant for employment or contract with a potential subcontractor to perform any duties that may be paid for directly or indirectly through a contract if the applicant or potential subcontractor is listed on LEIE.
4. Prohibit an employee or subcontractor listed on any LEIE from performing any duties that may be paid for directly or indirectly through a contract; and
5. if an employee or subcontractor is listed on either LEIE immediately report to the HHS Office of Inspector General, in accordance with the self-reporting protocol of the HHS Office of Inspector General:
   • the identity of an excluded employee or subcontractor; and
   • the amount paid by the contractor to the employee or subcontractor for services provided under a contract.