Employment ApplicationJob Application Applicant Information Full Name * Address Birthdate Cell Phone * Email * Can you receive Text Messages? Yes No Desired Salary Social Security Number Are you 18 years of age or older? Yes NoAre you legally entitled to work in the U.S.? Yes NoHave you ever worked for this company? Yes No When? Have you ever been convicted of a felony? Yes No When? Education High School City/State Did you graduate? Yes NoDid you obtain a GED? Yes No College From To Did you graduate? Yes No Degree Other Education From To Degree Did you graduate? Yes NoReferencesPlease list two professional references Do not include family, friends or acquaintances. Full Name Relationship Email Phone Full Name Relationship Email Phone Previous Employment Company Phone Address Supervisor Job Title Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Yes No Company Phone Address Supervisor Job Title Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? Yes NoMilitary Service Branch From To Rank at Discharge Type of Discharge If other than honorable, explain Background CheckKaiser Home Support Services, Inc. requires a comprehensive background check, which consists of prior employment verification, professional reference checks, education verification, and a State Nurse Aide registry check. In addition, criminal background and sex offender registry checks are required for each county and state where the applicant has lived in the past three years.Any applicant who has been convicted of a felony drug charge, theft, exploitation, murder, voluntary manslaughter, felony battery, controlled substance offense, or violent sex crime or battery against a dependent population will not be eligible for hire.I understand that I must submit the necessary information required to conduct a comprehensive background check and will not be placed with a client until these requirements are satisfactorily met. I further understand that I may be required to obtain an original copy of the county criminal background check results, the cost of which will be reimbursed. Initial * Tuberculosis (TB) Skin TestI understand that Kaiser Home Support Services, Inc. requires a current, negative Tuberculosis (TB) Skin Test to be completed prior to working with clients. I further understand that Kaiser Home Support Services, Inc. requires a current, negative TB Skin Test each year for continued employment, and I may not be eligible to work until this requirement has been satisfied. Initial * Drug TestingKaiser Home Support Services, Inc. has a zero tolerance Drug- and Alcohol-Free Workplace Policy and requires the following Drug and/or Alcohol Testing:- Post-injury Testing- Reasonable Suspicion TestingI understand that Kaiser Home Support Services, Inc. prohibits the use, possession, distribution, or sale of drugs or alcohol, or being under the influence of drugs or alcohol while in the workplace, during work hours, or on company premises or company time. I further understand that I will be subject to Drug Testing as described above, and any violation of Kaiser Home Support Services, Inc. Drug- and Alcohol-Free Workplace Policy will result in (a) ineligibility for employment or (b) termination of employment. Initial * Disclaimer & SignatureI certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release Full Name * Email * reCAPTCHA Submit
