join our team! Please fill out your application and employment history Please enable JavaScript in your browser to complete this form.Select State in Which You Are Applying to Work *KansasMissouriName *FirstLastLayoutDate of Birth *Social Security Number *All Known AliasesLayoutStreet Address *City *State *Zip Code *LayoutEmail *Alternate Phone NumberPhone *Are you 18 years of age or older? *YesNoPosition Applied ForAre you currently employed? *YesNoAre you related to your perspective client? *YesNoIf yes, how are you related? BackgroundHave you ever been convicted of, plead guilty to, or plead nolo contendere (no contest) to an offense other than a minor traffic violation? *YesNoIf yes, please list conviction(s), date(s) and location(s). The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. If yes, describe here (include all criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo contendere) (copy)Have you ever been investigated by the Department of Social Services, Children’s Division, Family Services, Department of Health and Senior Services, or any other agency for any type of abuse, neglect or wrongdoing of any sort? *YesNoHave you ever been listed on the Employee Disqualification List? *YesNoIf yes, please provide the reason. Have you ever applied for a Good Cause Waiver? *YesNoIf yes, when and why? Are you registered with the Family Care Safety Registry? *YesNoAre you legally eligible for employment in the U.S.? *YesNoHave you ever had any other Social Security Numbers? *YesNoIf yes, please list the other numbers. Do you have regular access to reliable transportation? *YesNoDo you have home care/personal care experience? *YesNoPlease list any certifications, professional designations and/or licenses you have.Employment History - Please complete for last five years.Company 1Company 1 Name *Supervisor Name *Phone *Company 1 AddressStreet Address *City *State *Zip Code *Company 1 Position and DatesPosition Held *Start Date *End Date *Duties *Reason For Leaving *Can we contact the employer? *YesNoCompany 2Company 2 Name Supervisor Name Phone Company 2 AddressStreet Address CityState Zip Code Company 2 Position and DatesPosition HeldStart DateEnd DateDutiesReason For LeavingCan we contact the employer? YesNoCompany 3 Company 3 NameSupervisor NamePhoneCompany 3 AddressStreet AddressCityStateZip CodeCompany 3 Position and DatesPosition Held Start DateEnd DateDuties Reason For Leaving (copy)Can we contact the employer? YesNoEducationPlease list name and location, course of study, years completed, and date graduated. LayoutHigh SchoolCollegeOtherReferencesList three credible references. Do not list relatives. Reference 1Name *Relationship *Phone *Ref 1 AddressStreet Address *City *State *Zip Code *Reference 2Name *Relationship *Phone *Ref 2 AddressStreet Address *City *State *Zip Code *Reference 3Name *Relationship *Phone *Ref 3 AddressStreet Address *City *State *Zip Code *Emergency Contact InformationEmergency ContactName *Relationship *Cell Phone Number *Work Phone Number *Availability Please check all that apply.LayoutDays Available *MondayTuesdayWednesdayThursdayFridaySaturdaySundayHours Available *Day HoursEvening Hours (5-9 p.m.)Nights (9 p.m.-12 a.m.)OvernightsLive-InAcknowledgement for Kansas ApplicantsAspire Home Health, Inc is an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap or military status. I attest that the above referenced information is true and accurate to the best of my knowledge. I further give the agency permission to call any of my cited previous employers or reference candidate and do all required background/registry checks that are required for consideration for employment at the agency. Type Your Name to Sign *I agree to the above-mentioned statements and consent to a criminal record check and to a closed record check pursuant to State of Kansas Regulations. DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. Acknowledgement for Missouri ApplicantsI certify the answers herein are true and accurate to the best of my knowledge and I hereby authorize consent to pre- employment criminal record checks for employment purposes only. I hereby give consent to performance of a closed records check. I understand any employment with Aspire Home Health, Inc. is conditioned on my consent to such checks as well as the findings/results of such checks. I hereby release any person or organization conducting such background checks and/or furnishing such criminal record information and Aspire Home Health, Inc. from any and all liability arising out of the conducting of a check or the furnishing or receipt of criminal record information. Any such person or organization may rely on a copy of this release. In the event of employment with Aspire Home Health, Inc. I understand that false or misleading information given on this application or in interview(s) may result in refusal to hire or, if employed, may result in termination upon discovery. I understand that I am applying for employment with Aspire Home Health Inc. and the consumer (please identify the consumer below) who is authorized for Consumer Direct Services through the Department of Health and Senior Services (DHSS). If I am hired by this CDS Participant, then they will be my employer until I quit or they terminate my employment. Aspire Home Health, Inc. is the DHSS Authorized Provider for this CDS Participant. Consumer Name (if known)FirstLastType Your Name to Sign *By signing above, I agree to the above-mentioned statements and consent to a criminal record check and to a closed record check pursuant to State of Missouri Regulations. DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. Submit
