249 Post Ave
Westbury NY 11590
Phone: 516-307-8066
Fax: 516-740-5855

Covid-19 Advisory Statement

Application for Employment

Personal Information

Name Email Social Security #
Present Address
Permamnent Address
Phone # If you are under 18, can you furnish a work permit? Yes No
Employment desired Full Time Part Time Temp Seasonal
Position Date you can start Salary
Are you employed now? If so may we enquire of your present employer? Yes No
Ever applied for this company before? Yes No
Are you on layoff and subject to recall? Yes No Will you travel if required? Yes No
Will you relocate if job requires it? Yes No Will you work overtime if required? Yes No
Are you able to meet the attendance requirements of this position? Yes No
Have you ever been Bonded? Yes No
Have you ever been convicted of a felony in the past 7 years? Yes No

Sunch conviction may be relavent if job related, but does not bar you from employment. If yes - explain
Driver's license number State
Education Name of School School Location # of years Completed Did you Graduate Subjects Studied Degree Obtained
Academic Currently Attending
Last Completed
Trade of Business Currently Attending
Last Completed

Summarize special skills and qualifications acquired from employment or other experience that may qualify you to work with this company:
From To Name and address of employer Salary Job Reason for Leaving

References: Give the name of three persons not related to you to whom you have known at least 1 year

Name Address Phone Yrs acquainted

List any foreign language(s) and check the box that best describes your skills level

Language Read and write Read and speak Speak only Read/Write/Speak
In case of Emergency notify
Name: Address: Relationship: Phone:

INITIAL Condition of Employment - please read carefully

Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service, if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company. Panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

This application is current for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

Signature By Entering your name in the above line constitute your signature Date

BACKGROUND CHECK CONSENT

Name Date
Home Address

I, , have had no prior convictions of an offense which would potentially bar employment as listed below:

Convicted of the following offenses, any Class A felony defined in the Penal Law; any Class B or C felony occurring within ten years preceding the date of the criminal history check; any Class D or E felony listed in Article 120, Article 130, Article 155, Article 160, Article 178 or Article 220 of the Penal Law occurring within the last 10 years any crime defined in Sections 260.32 or 260.34 of the Penal Law occurring within 10 years of the criminal history check; or; any comparable offense in any other jurisdiction.

CRIMINAL HOMICIDE KIDNAPPING & FALSE IMPRISONMENT
INDECENCY WITH A CHILD AGREEMENT TO ABDUCT FROM CUSTODY
SOLICITATION OF A CHILD SALE OR PURCHASE OF A CHILD
ARSON ROBBERY
AGGRAVATED ROBBERY ASSAULTIVE OFFENSES
THEFT BURGLARY & CRIMINAL TRESPASS
WEAPONS FRAUD
PUBLIC LEWDNESS INDECENT EXPOSURE
PUBLIC INDECENCY A FELONY VIOLATION OF A STATUTE INTENDED TO CONTROL TILE POSSESSION OR DISTRIBUTION OF AN ILLEGAL SUBSTANCE

I UNDERSTAND THAT THE HOME CARE AGENCY IS REQUIRED TO CONDUCT A CRIMINAL HISTORY CHECK BEFORE OFFERING ME EMPLOYMENT.

I, THE UNDERSIGNED, HEREBY AUTHORIZE THIS AGENCY TO CONDUCT AND VERIFY MY CRIMINAL HISTORY BY PERFORMING A CRIMINAL HISTORY CHECK.
Signature By Entering your name in the above line constitute your signature Date

CRIMINAL HISTORY SEARCH CONSENT FORM

Name Date

, have had no prior convictions of an offense described in the Health and Safety Code which would bar or potentially bar employment as listed below.

CRIMINAL HOMICIDE KIDNAPPING & FALSE IMPRISONMENT
INDECENCY WITH A CHILD AGREEMENT TO ABDUCT FROM CUSTODY
SOLICITATION OF A CHILD SALE OR PURCHASE OF A CHILD
ARSON ROBBERY
AGGRAVATED ROBBERY ASSAULTIVE OFFENSES
THEFT BURGLARY & CRIMINAL TRESPASS
WEAPONS FRAUD
PUBLIC LEWDNESS INDECENT EXPOSURE
PUBLIC INDECENCY A FELONY VIOLATION OF A STATUTE INTENDED TO CONTROL THE POSSESSION OR DISTRIBUTION OF AN ILLEGAL SUBSTANCE (NEW YORK CONTROLLED SUBSTANCE ACT)

I UNDERSTAND THAT THE HOME CARE AGENCY IS REQUIRED TO CONDUCT A CRIMINAL HISTORY CHECK BEFORE OFFERING ME EMPLOYMENT.

I, THE UNDERSIGNED, HEREBY AUTHORIZE THIS AGENCY TO CONDUCT AND VERIFY MY CRIMINAL HISTORY BY PERFORMING A CRIMINAL HISTORY CHECK.

I UNDERSTAND THAT THE HOME HEALTH AGENCY IS REQUIRED TO CONDUCT A CRIMINAL HISTORY CHECK BEFORE OFFERING ME EMPLOYMENT. I, THE -UNDERSIGNED, HEREBY AUTHORIZE THIS AGENCY TO CONDUCT AND VERIFY MY CRMINAL HISTORY BY PERFORMING A CRIMINAL HISTORY CHECK.
Signature By Entering your name in the above line constitute your signature Date

VERIFICATION OF PROFESSIONAL LICENSE

Employee Name
✓ CHECK OFF DISCIPLINE NEEDING VERIFICATION
RN RT OT LPN HHA
LICENSE NUMBER EXPIRATION DATE OF LICENSE
DATE VERIFIED
LICENSE VERIFIED BY Written Phone Fax
Upload Photo ID Upload Professional License
Action Outstanding Yes No
Comments
I HAVE READ THE LICENSE OF THE ABOVE INDIVIDUAL ACCORDING TO THE AGENCY POLICY. THE LICENSE IS CURRENT AND IN GOOD STANDING WITH THE STATE OF NEW YORK.
Signature By Entering your name in the above line constitute your signature Date