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Personal Data

Address - (List'all addresses from past seven (7) years Use back of form if necessary.)


Education



Employment

List all employment during the past 10 years.


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U.S. MILITARY - (Active Duty including Reserve or National Guard Service)

COMPUTER SKILLS - (Active Duty including Reserve or National Guard Service)

Languages

BACKGROUND INFORMATION

When completing this section, do not disclose information regarding convictions that have been Judicially erased, sealed, expunged, eradicated, Impounded, or dismissed. Do not disclose information regarding juvenile court convictions or minor traffic violations. A conviction record does not automatically bar you from employment. All of the job-related circumstances surrounding convictions will be considered.

BUSINESS REFERENCES

Name Job Title Address Telephone Number

TRANSPORTATION

Abuse Investigation

AUTHORIZATION AND UNDERSTANDING

RELEASE OF PRIOR PERSONNEL INFORMATION


By signing this application, I agree that all of the information now or later given by me in support of my application for employment is true and complete. I understand that you may verify any of the information concerning my employment, education, credit, or medical history with the appropriate individuals, organizations, or governmental agencies. I give these Individuals, organizations or governmental agencies my permission to release any information that you need, including my previous disciplinary record, without requiring them to contact me or give me a written notice before revealing the information to you. I understand that no verification of my credit history or request for a 'consumer report' under the Fair Credit Reporting Act may be undertaken by you without my express written authorization in a separate document. By signing this application, and in the case of a consumer report under the Fair Credit Reporting Act, should I sign the separate Authorization for credit reports on my own, I release you and them from any liability whatsoever arising out of an information request or disclosure. I agree that any false information in support of my application may subject me to discharge at any time during my employment.

AT-WILL EMPLOYMENT STATUS


I AGREE THAT EITHER PARTY MAY TERMINATE THE EMPLOYMENT RELATIONSHIP, WITH OR WITHOUT CAUSE, AT ANY TIME, FOR ANY REASON, AND I FURTHER AGREE THAT THIS AGREEMENT MAY ONLY BE CHANGED BY THE PRESIDENT OF THE COMPANY, IN WRITING, DIRECTED TO ME PERSONALLY, AND SIGNED BY THE PRESIDENT. I agree that is shall be bound by the other rules, regulations, and terms and conditions of employment of the company as they are from time to time changed and that no additional obligations ban be imposed by me on the company except those which have been acknowledged, in writing, by the company president or his/her designated representative. I further agree that my employment is conditional upon satisfactory completion of documentation as required by the Immigration Reform and Control Act of 1986 and until such time as the result of my pre-employment physical (if such physical is required) are known.

AT-WILL EMPLOYMENT STATUS


I authorize the Company to contact my previous employers for work-related references.

RELEASE FOR BACKGROUND SCREENING


I authorize the Company to verify any information that I provide in connection with my employment. I release the Company and its authorized representatives of all liability resulting from the use of background information about me for employment purposes.

Offer Letter

Dear

On behalf of Blessing Hands Home Care, it gives me great pleasure to offer you the position of Community Relations Coordinator. You will be reporting directly to Ana Barajas Care Manager and Anna Tamayo Caregiver Supervisor and your start date will be on

We are offering you the following compensation package:
• You will be paid at the see pay roll sheet, rate of: $
• Overtime Rate(s) of pay: 5
• Regular Pay dates are:
• Allowances, if any, claimed as part of minimum wage (including meal or lodging):
• You will be reimbursed per company's mileage reimbursement policy for all miles driven for business purposes.
• You are eligible for Paid Time Off (PTO) in accordance with agency's PTO policy.
• You are eligible for Paid Sick Leave in accordance with agency's Sick Leave policy and state requirements.
• You are eligible to participate in agency's benefit plans on the first of the month following thirty (30) days of employment. Agency's comprehensive benefits package includes:


This offer is contingent on the Agency's verification of credentials and other information required by State/other law and Agency policies, including verifying clearance on the home care aide registry, the completion of a criminal record statement, and is contingent upon your passing a medical examination - which includes a TB examination clearance. Further, you must produce documents required under the Immigration Reform and Control Act establishing your legal right to work in the United States, our satisfactory completion of background and reference checks, and your signing the attached agreements covering employment related covenants.

Employment at Blessing Hands Home Care is "at-will". This means that your employment may be terminated at any time, with or without cause, and with or without notice, by you or by the Company. Any contrary representations or agreements which, may have been made to you, are superseded by this offer. The "at-will" nature of your employment described in this offer letter shall constitute the entire agreement between you and the Company concerning the duration of your employment and the circumstances under which either you or the Company may terminate the employment relationship. No person affiliated with the Company has the authority to enter into any oral agreement that changes your "at-will" status of employment with the Company. This "at-will" relationship can only be changed by an agreement in writing signed by the Chief Executive Officer, and approved in writing by our general counsel. By signing below and accepting this offer, you acknowledge and agree that length of employment, promotions, performance reviews, pay increases, bonuses, increases in job duties or responsibilities and other changes during employment will not change the "at-will" terms of your employment with the Company and will not create any implied contract requiring cause for termination of employment.

Non-Solicitation of Clients

THE EMPLOYEE agrees not to solicit or accept independently any clients of THE EMPLOYER during their employment with THE EMPLOYER and for a period of ONE YEAR after termination of employment with THE EMPLOYER.

If you are in agreement with the provisions of this offer, please sign and date the original of this letter within 7 calendar days acknowledging your understanding and acceptance of this employment offer, retain a copy and return the criginal to the hiring manager.

Employee Handbook Acknowledgment Form

I, have reviewed Blessing Hands Home Care Employee Handbook.


REFERENCE CHECK AUTHORIZATION

I, have applied fo employment with Blessing Hands Home Care. I authorize them to collect any and all information concerning my qualifications and performance while associated with your company. Further, I hereby release the company or person completing this form from any and all liability supplying the requested information.


APPLICANTS - DO NOT WHRITE BELOW THIS SECTION

REFERENCE CHECK


Select an appropriate responses below:
Select an appropriate responses below:

HEPATITIS B VACCINATION WAIVER

I elect not to be vaccinated at this time. I understand that due to the nature of my professional responsibilities, I may be at risk for acquiring the Hepatitis B virus (HBV). 1 have been given the opportunity to be vaccinated against Hepatitis B at no cost to myself, and I have declined the vaccination. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. 1 understand that if I so choose, I can elect to receive the vaccination series in the future.

I have completed the 3-dose Hepatitis B vaccine on the following dates:

Employee Confidentiality Agreement

Privacy Policy

Confidential information is defined as any information found in a patient's medical information,, personal information, and work-related information (including salary information). All information relating to a patient's care, or condition constitutes confidential information.

Employees shall never discuss a patient's medical condition with any non-employee of the company, friends or family members unless specified. Confidential matters involving patients will not be discussed in areas where they might be overheard by other patients or other non-employees of the company. Staff members are to be aware at all times that conversations regarding patients are not to be overheard by others and take appropriate steps to ensure this confidentiality.

All salary information is confidential and may not be shared with others in the company or with patients. Only authorized individuals may relay salary information to employees or non-employees.

Any unauthorized disclosure of confidential information by employees could render the company liable for damages. Any employee who violates the confidentiality of the company, patient medical or employee related information is subject to disciplinary action up to and including termination from employment.

I have received a copy of, read, understand, and agree to uphold this written polley on matters of confidential Information.
I also understand that in my daily job duties, I will have access to patient medical information and any violation of confidentiality,in whole or in part, could result in disciplinary action up to and including termination and/or legal action.
I recognize that this signed document of my agreement to uphold the provisions of this policy will be kept on He in my personnel file.


October 11, 2017


To: All Caregivers

Blessing Hands will have a new payroll system as of October 15, 2017. The system will be as follows;
The first pay period of the month will be from the 1st through the 15th and will be paid on the 20th.

The second pay period will be from the 16th though the 31st and paid on the 5th

It will be your sole responsibility to turn in your time sheets. They are due in the office on the 16th and

the 1st of each month. Anything not turned in on time will not be processed until the following pay period. Should the 16th or 1st fall on a Saturday or Sunday, they are to be turned in on the Monday.


Thank you.

EMPLOYMENT CANDIDATE INTERVIEW FORM

Interview Points

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