Employment Compassionate, Personal Care in Your Home

Family Home Care Services is a licensed, bonded and insured agency.

All fields marked with ( * ) are required.

Personal Information

Previous Address is required if above address is less than 5 years




Employment Information


List the exact times you are available:

*Monday: *To: Comments:
*Tuesday: *To: Comments:
*Wednesday: *To: Comments:
*Thursday: *To: Comments:
*Friday: *To: Comments:
*Saturday: *To: Comments:
*Sunday: *To: Comments:

Qualifications & Experience

Education: Name of School City State Did you graduate?
*High School
College
Technical Training


PAST & PRESENT EMPLOYERS

Please list all present and past employers for the past 5 years




















Personal References

(Must include 1 reference that has known you for over 5 years.
Do not list any relatives or duplicate a supervisor from your employment history)


CRIMINAL BACKGROUND INQUIRY



I authorize FHCS, LLC to complete a pre-employment background screening

"I certify that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you."



AGREEMENT, AUTHORIZATION, AND CONSENT FOR RELEASE OF BACKGROUND INFORMATION
PLEASE TYPE OR PRINT

I,

Understand that in conjunction with my application for employment, work to be performed under contract, promotion, volunteer position, reassignment, and/or retention (“Work”) Family Home Care Services will use the services of an outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing, work history and qualifications. This agency will provide a written report of its findings to Family Home Care Services. Family Home Care Services uses Intellicorp, Records Inc., a consumer-reporting agency, as an agent to perform its employment related background investigations.

Intellicorp Records, Inc. will utilize various sources of information it deems appropriate including but not limited to: criminal conviction records, current and former employers, department of motor vehicle records, military records, credit reporting agencies, education records, professional and personal references and workers compensation records including any and all injuries in compliance with the American Disabilities Act. I agree, authorize and consent to the release and disclosure of any and all information including but not limited to the above to Family Home Care Services and Intellicorp Records, Inc.

I agree, authorize and consent to the procurement of a Consumer Report and/or an Investigative Consumer Report and understand that it may contain information about my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This authorization in original or copy form shall be valid for my term of work from the date indicated next to my signature. I understand and agree that where applied an electronic signature filed in an electronic form shall have the same legal force and effect as my hand written signature. According the Fair Credit Reporting Act, I will be notified by Family Home Care Services if work is denied because of information obtained from a consumer reporting agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to Family Home Care Services. I further understand that I may request a copy of the report, and that when doing so, proper identification will be required and I should direct my request to: Intellicorp Records, Inc., 3000 Auburn Dr. Suite 410 Beachwood, OH 44122. Phone # 1-888-946-8355. Website: www.intellicorp.net. I understand that residents of all states will automatically receive a copy of the report if an adverse action is taken regarding the employment application, or upon request as outlined herein.

LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE INDENTIFICATION PUPOSES REQUIRE THE FOLLOWING INFORMATION WHEN CHECKING PUBLIC RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER PURPOSES, PLEASE PRINT CLEARLY.

Other names you have used or also known as, including maiden name, name changes and any aliases

PLEASE PROVIDE ALL RESIDENTIAL ADDRESSES FOR THE PAST 7 YEARS



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