6/24/2013
Dear Applicant,
Thank you for choosing TLC Home Health Care, a family-owned and operated agency. We pride ourselves in our contribution to the home health industry by providing job opportunities to thousands of individuals while our clients are being served in the comfort of their own homes on a 2-hour to a 24-hour basis. Our system has evolved over the last twenty (20) years that consistently responds to the changes of the time. We encourage you to join our team in making a difference in the lives of the elderly and the disabled.
In our goal to ensure employee and client safety, we subject our applicants to the following pre-employment requirements:
q Six (6) verifiable previous employer and personal references
q Six (6) months healthcare related experience, caregiver experience; previous or current state issued C.N.A license is recommended
q Tuberculosis Test (on-site). If positive, Chest X-ray and/or a physician’s note clearing you of the disease will be required
q Valid CPR Card (BLS preferred)
q Current Driver’s license or State issued I.D. card
q Social Security Card, Birth Certificate or Alien Registration, with photo
q Fingerprints: passing a criminal history Background Check, required through the Department of Health & Welfare
q Reliable transportation and telephone number
q DMV Driving Record Printout
q Current Auto Insurance, with your name on the policy
q Caregiver Education test/training (on-site)
q A Pre-employment, in-office, Drug Screening and a two (2) hour Human Resources Orientation
For your convenience, we will provide you with a list of institutions and agencies that can conduct CPR classes, Visions and/or Med Certification Training. After you are finished completing these, you may schedule orientation and begin employment. However, the agency will not put you to work until you have successfully passed the criminal history background check. We would be happy to assist you the best way we can.
You may reach us at (208) 853-5050, Monday through Friday from 9am to 5pm.
Please complete the attached application form. Please do not leave any spaces blank.
Write N/A if not applicable.
If you are unable to meet the above pre-employment requirements at this time, we would be pleased to discuss future employment opportunities with you. *Application submission does not guarantee employment.
We look forward to having you as a member of our family.
Sincerely,
Management & Staff
TLC Home Health Care
7456 W. State St
Boise ID, 83714
Ph (208) 853-5050
Fax (208) 853-9852
www.tlchhcidaho.com
Employment Requirements
For your convenience, here is a list of institutions and agencies that may assist you in completing the pre-employment requirements. 8-hours of Basic Training is recommended within the first 90 days of employment for those applicants that do not hold a C.N.A. certification or have previous experience as a caregiver. While you are completing these requirements, you may still schedule orientation with the Human Resources Director thru our office. We would be happy to assist you the best way we can. You may reach us at (208) 853-5050 and/or our fax (208) 853-9852 Monday through Friday, between 9:00AM to 5:00PM. Thank you for your interest in becoming a part of our family. We look forward to having you on board.
q CPR Card (current)
CPR Lifesaver (Jeanie 939-8624)
$25.00 Approx. 2 hours long.
*Please call to register for a class.
q Fingerprint Clearance Letter/Verification
Department of Health & Welfare $65.00 - Appointment Only
Applicants must register online at www.chu.dhw.idaho.gov to begin the process. Go to new user registration, set up a user name and password, then log in. Select “complete self-declaration/application”; please remember to input the Employer Information in the employer field: #1113. Be sure to mark on the self-declaration that you are applying for the Personal Assistance and Personal Care Providers, NOT Home Health. If you have any further questions, please call our office.
***If fingerprinted within the past three (3) years, applicants may obtain verification from the Idaho State Police Dept, their current fee is $20.00. See our HR Director for the ISP form.
______
After you have been fingerprinted, you will need to turn in documentation / verification of completion to the Human Resources Director at TLC Home Health Care. Fingerprints will be processed through the Department of Health & Welfare and Department of Justice via the State of Idaho. Cost is $65.00 for the processing. TLC does not, typically, pay for fingerprinting; however, if you need assistance, speak with our Human Resources Director.
______
Once all requirements are completed, you will need to attend:
q 2-hour TLC Human Resources Orientation
TLC APPLICATION FOR EMPLOYMENT
Personal Information
Please do not leave any space blank. Write “N/A” if not applicable.
Date ______
Name (Last, First, MI) ______
Previous/Maiden Name ______Are you over 18 years of age? ______
Address ______
City ______State ______Zip Code ______
Home phone ( )______Cell ph ( ) ______Message ph______
DOB ______Are you a smoker? Y N
Can you refrain from smoking while at work? Y N
EMPLOYMENT DESIRED
Position Applied for ______Date you can start ______
Select desired shift:
Day / Evening / Overnight / Weekends ONLY / Weekdays ONLY / OthersPlease list hours of availability each day:
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / SundayHow did you learn of this opening?
Have you ever applied to TLC Home Health Care? Yes □ No □
Previously worked for TLC, A Caring Hand, Advanced, Above and Beyond or Absolute? Yes □ No □
If yes, when? Agency: ______Supervisor: ______
Reason for Leaving: ______
Have you ever been convicted of a felony? Yes □ No □
If yes, when? Year (s) ____
*Briefly explain ______
EDUCATION
Circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16+
Location / Date Attended / Degree EarnedHigh School / N/A
College/University
Trade/Vocational
Other
EMPLOYMENT HISTORY
PLEASE FOLLOW THESE INSTRUCTIONS: Please give the details of your previous jobs. Provide all information requested, including City, State, Zip Code, Telephone and if possible Fax Number; otherwise, this application may not be processed.
Position:______/ Employer / Address
(Street Name/Number, City, State, Zip Code) / Telephone & Fax / Supervisor
From ______
To
______/ Telephone #:
( ) ______
______Fax # :
( ) ______
______/ Name:
______
Position:
______
Position:
______/ Employer / Address
(Street Name/Number, City, State, Zip Code) / Telephone & Fax / Supervisor
From ______
To
______/ Telephone #:
( ) ______
______Fax # :
( ) ______
______/ Name:
______
Position:
______
Position:
______/ Employer / Address
(Street Name/Number, City, State, Zip Code) / Telephone & Fax / Supervisor
From ______
To
______/ Telephone #:
( ) ______
______Fax # :
( ) ______
______/ Name:
______
Position:
______
*May we contact your current employer at this time? Yes □ No □
Language(s) spoken: ______
What skills/experience do you have that would be useful in this line of work? ______
Tell us about yourself ______
What do you hope to learn or experience if employed with TLC Home Health Care?______
______
REFERENCES
PLEASE FOLLOW THESE INSTRUCTIONS: *Excluding relatives and former employers*, list three references. You must provide all requested information including Street Name/Number, City, State and Zip Code, Telephone number; otherwise this application may not be processed.
Name / Address(Street Name/Number, City, State & Zip Code) / Telephone & Fax / Years
Acquainted
First Name:
______
Last Name:
______/ Telephone #:
( ) ______
______Fax # :
( ) ______
______
Name / Address
(Street Name/Number, City, State & Zip Code) / Telephone & Fax / Years
Acquainted
First Name:
______
Last Name:
______/ Telephone #:
( ) ______
______Fax # :
( ) ______
______
Name / Address
(Street Name/Number, City, State, & Zip Code) / Telephone & Fax / Years
Acquainted
First Name:
______
Last Name:
______/ Telephone #:
( ) ______
______Fax # :
( ) ______
______
______
EMERGENCY CONTACT INFORMATION
______
Name Phone # Relationship
What is your mode of transportation? Check the one that applies:
□ Bus
□ Self-Owned Car
□ Other (must specify) ______
Do you have any restrictions that we need to consider if/when we staff you?
□ Yes (please specify)
______
______
□ No
Do you currently hold any state licenses or certificates/cards of education?
□ Yes (please list) ______
______
□ No
EMPLOYMENT AGREEMENT
This agency does not discriminate in hiring based on race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, age, physical, or mental disability. No information requested on this application is intended to secure information to be used for such discrimination.
*I voluntarily give this agency the right to make a thorough investigation of my past employment and activities. I also agree to cooperate in such investigation and release from liability or responsibility all persons companies or corporations supplying such information. I consent to take the physical examination, and future physical examinations as may be required. I understand that my employment may be contingent on the completion of the pre-employment requirements, current CPR Card, TB Test/Chest X-ray, Fingerprints/Criminal History Clearance, valid proof of identification, Caregiver Training, Human Resources Orientation, as these relate to the essential duties that I would be required to perform.
*I understand that my employment is at will; either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9), present satisfactory evidence of identity and eligibility of employment.
X Applicant Signature ______X Date______
EMPLOYMENT VERIFICATION
AUTHORIZATION TO RELEASE INFORMATION
I, x______, authorize this Employer to release information to
(First Name) (Last Name)
TLC Home Health Care. I also release the employer from any and all liability resulting from the release of such information. I understand that the employer, if so directed by the court, may release other information.
Position Applied for: * Personal Care Attendant/Caregiver * Other: ______
Applicant’s Signature X______
Social Security Number X______
**************************************APPLICANTS*STOP*HERE PLEASE***************************************
We would like to verify employment for the above named individual. In order for us to process this application, we would like the following information completed. Please return the requested information to: (208) 853-9852 (fax) Attention: Human Resources Director. Thank you!
Employer: / Requested Info / Reason for LeavingCurrently Employed? / Yes No
Eligible for Rehire? / Yes No
Dates of Employment:
Position Held:
Supervisor Signature Date
______
Printed Name Title
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