Work With Us| Nashville TN| Trueloves Health Care Services

First Name

Last Name

Phone:

SSN

Physical Address

City

Zip

Telephone Numbers

Date Of Birth

Email

Can you verify that you meet the following qualifications: Are you at least 18 years of age; able to meet the physical and mental demands required to perform specific tasks of the consumer; agree to maintain confidentiality; be emotionally mature and dependable; be able to handle emergency situations; and not be the consumer's spouse? (please select one)

Yes

No

Do You Smoke

Yes

No

Have you lived in Tennessee for the past 7 years?

Yes

No

If NO, please list the state you resided in:

How did you learn of this position?

Are there any reasons why you would not be able to perform the job duties?

Yes

No

If YES, please describe the reason:

Background

Background: A background screening via the TBI must be performed prior to the first day. Have you been charged with an offense other than a minor traffic violation? YES or NO Please disclose all criminal convictions, findings of guilt, plea of guilt, and pleas of nolo contendere or provide a statement there is no record of such background. Failure to disclose any criminal information is a violation of the law. If this do not apply please use N/A.

Have you used any alias or different Social Security Numbers?

Yes

No

If yes, please explain

Have you ever been convicted of any criminal convictions, findings of guilt or plea of guilt?

Yes

No

Plea of nolo contendere, except minor violations?

Yes

No

I give Truelove's In-Home HC consent to conduct a pre-employment criminal record check?

Ye

N

If no, please explain

Have you ever been registered on the TN Abuse or Sexual Offender Registry?

Yes

No

Military Record

Military Record:

Branch of Service

Rank/Discharge Date

Authorization:

Authorization:

New Field:

I Certify that the facts contained in this application are true and complete to the best of my knowledge and 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 and employers listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release Truelove's In-Home Health Care from liability for any damage that may result from utilization of such information. I also understand and agree that no representative of Truelove's In-Home Health Care has any authority to enter into an agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized agency representative.

Attendant Signature

Emergency Contact

Do you have a skilled license?

Yes

No

If yes, please describe, along with license #

Do you have reliable transportation to work?

Yes

No

Do you have a valid Driver's License?

Ye

No

Have you ever worked with people with physical/cognitive disabilities?

Ye

No

If yes, please explain the duties:

Free Text

AVAILABILITY

Do you prefer working with males, females, or either?

Yes

No

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Begin

Sun

Mon

Tues

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Sat

End

End

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

Please circle the following duties that you are willing and able to perform on a daily basis

Personal References

PERSONAL REFERENCES (one (1) that you have known for at least five (5) years)

Name

Relationship

Address

Telephone

Name

Relationship

Address

Telephone

Name

Relationship

Address

Telephone

EMPLOYMENT HISTORY

EMPLOYMENT HISTORY

Company Name

Supervisor

Dates Employed

Position

Duties

May we contact this employer?

Yes

N

Reason for leaving

Phone Number

Salary

Company Name

Supervisor

Dates Employed

Position

Duties

May we contact this emplyer?

Yes

No

Reason for leaving

Phone Number

Salary

Company Name

Supervisor

Dates Employed

Position

Duties

May we contact this employer?

Ye

No

Reason for leaving

Phone Number

Salary

I certify that the answers given are true and complete to the best of my knowledge and I hereby grant permission for a background screening via the TBI to be performed for employment purposes.

Signature of Applicant

Date

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