Employment Application – Subtle Whisper Elite Care

Best Home Health Care Agency in AR

Join the Subtle Whisper Family

Thank you for your interest in joining our family. Please fill out the application below. The application will take approximately 20 minutes to complete. Please fill out all fields entering N/A when needed. If your qualifications meet our requirements, we will be in touch.

Available Positions

Home Health Aid

Contract Nurse

Home Health Aid

Contract Nurse

Position Applying For:

Date:

Prefix

First Name *

Middle Name

Last Name *

Social Security # *

Date of Birth *

Month *

Day *

Year *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Phone *

Email Address

Date Available for Work

Month

Day

Year

Type of Employment DesiredFull-timePart-timeTemporaryPRN

Have you ever worked for Subtle Whisper Elite Care before? *YesNo

Are any of your relatives employed by Subtle Whisper Elite Care *YesNo

If Yes, who?

Education

Name of High School

Dates Attended

Graduated/Degree

Name of College

Dates Attended

Graduated/Degree

Other School Attended

Dates Attended

Graduated/Degree

Employment History

Company Name

Job Title

Street Address

City

State/Province

ZIP / Postal Code

Country

Supervisor Name

Supervisor Phone

Starting Wages

Ending Wages

Reason for Leaving

May We ContactYesNo

Company Name

Job Title

Street Address

City

State/Province

ZIP / Postal Code

Country

Supervisor Name

Supervisor Phone

Starting Wages

Ending Wages

Reason for Leaving

May We ContactYesNo

Company Name

Job Title

Street Address

City

State/Province

ZIP / Postal Code

Country

Supervisor Name

Supervisor Phone

Starting Wages

Ending Wages

Reason for Leaving

May We ContactYesNo

Professional References (Excluding Family)

I agree that by submitting this form I authorize Subtle Whisper Elite Care, or its agents to make inquiry of my employment history. Further, I hereby give consent to persons, schools, my current employer (if stated above) and previous employers named in this application (and accompanying resume, if any) to provide relevant information as may be requested by Subtle Whisper Elite Care for the purpose of making an employment decision. I agree that the submission will be the same as my written signature.

Name

Occupation

Relationship

Phone

Name

Occupation

Relationship

Phone

Name

Occupation

Relationship

Phone

Availability

Sunday Morning

Sunday Evening

Sunday Night

Monday Morning

Monday Evening

Monday Night

Tuesday Morning

Tuesday Evening

Tuesday Night

Wednesday Morning

Wednesday Evening

Wednesday Night

Thursday Morning

Thursday Evening

Thursday Night

Friday Morning

Friday Evening

Friday Night

Saturday Morning

Saturday Evening

Saturday Night

Professional Information

Have you ever been convicted of a felony? YesNo

Are you able to work with patients who smoke? YesNo

Are you able to work with patients who have pets? YesNo

Are you able to work holidays?YesNo

Do you have car insurance? YesNo

CNA License #

Issuing State

Has you CNA license ever been revoked, refused, or suspended? YesNo

CNA Skill Assessment Checklist

This checklist is designed to serve as a general guideline as to your level of skills in each of the following areas. Please rate your ability as accurately as possible by checking the appropriate box.Experience Level: 1=Never performed; 2=Limited experience; 3= Experienced; 4= Highly Experienced

Postmortem Care1234

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that intentional false statements could lead to my dismissal as an employee or rejection as an applicant. I understand that any employment relationship with SWEC is of an “at-will” nature. It is further understood that this at-will employment relationship may not be changed by any written document or by conduct. I understand that a drug and/or alcohol test may be required prior to employment and that any job offer is conditioned on satisfactory results of the test. I also understand that post-accident and random drug and alcohol testing may be done. I further voluntarily agree to such tests.

I understand that conviction of a crime may disqualify me from employment and that SWEC may request a criminal record check following any job offer. I also understand that any job offer is conditioned on satisfactory results of the criminal record check. This application is valid for 45 days. At the end of 45 days, if I have not heard from SWEC and still wish to be considered for employment, it will be necessary to fill out a new application. I agree that by submitting this form I am attesting to the accuracy of all information and that the submission will be the same as my written signature.

Signature

Digital Pin

Arkansas Department of Human Services Request for Adult Maltreatment Registry Information

Prefix

First Name *

Middle Name

Last Name *

Date of Birth *

Month *

Day *

Year *

Maiden Name and/or Any Names Formerly Uses

Social Security Number *

Current Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Dates

Previous AddressList all previous addresses for the past five years. (Attach additional pages if needed.)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Dates

Authorization

I authorize Department of Human Services/Adult Protective Services to release information from the Adult Maltreatment Central Registry in accordance with Ark. Code Ann. § 12-12-1717 to the following:

Agency Name/Contact Person

Mailing Address (Street or PO Box, City , State, Zip)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Agency type: Volunteer (no charge)Non-Profit (no charge)State Agency(no charge)All Others ($33.00 Fee)

Certification

I further certify that the information provided on this form is true and correct.

Signature

Date

COUNTY OF ___________________

STATE OF ARKANSAS

Acknowledged before me this ________ day of __________________, 20_____.

___________________________________ _____________________ [SEAL]

Notary Public My Commission Expires

For APS use only:

The above named applicant was _____ / was not _____ listed in the Adult Maltreatment Central Registry.

Verified by: ________

Child Abuse Clearance Authorization

Prefix

First Name

Middle Name

Last Name

HTML

understand that as part of Subtle Whisper Elite Care’s employment, roster or contract processes, I will be required to undergo a child abuse history clearance.

I hereby give my consent for Subtle Whisper Elite Care to request a Child Abuse History Clearance be conducted on me.

Furthermore,

I authorize all federal and state agencies, persons and organizations that may have information relevant to this research to disclose such information to Subtle Whisper Elite Care or its authorized agent(s).
I understand that this authorization is to be part of the written and signed employment or contract application.
I also understand that I do not have to give authorization for a child abuse history clearance but if I don’t give permission, my employment application will not be processed further.
I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.
I further authorize that a photocopy of this authorization may be considered as valid as the original.
I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment or contract with Subtle Whisper Elite Care is contingent upon a successful child abuse history clearance.

SignatureI understand that typing my full name serves as my digital signature

Date

Prefix

First Name

Middle Name

Last Name

Former Name(s) and Date(s) Used:

Current Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth

Month

Day

Year

Current Driver's License Number:

State:

List any other cities, states and dates of residency during last 10 years

SERVICING THE FOLLOWING COUNTIES AND CITIES :

Best Home Health Care Agency in AR

Join the Subtle Whisper Family

Available Positions

Education

Employment History

Professional References (Excluding Family)

Availability

Professional Information

CNA Skill Assessment Checklist

This checklist is designed to serve as a general guideline as to your level of skills in each of the following areas. Please rate your ability as accurately as possible by checking the appropriate box.Experience Level: 1=Never performed; 2=Limited experience; 3= Experienced; 4= Highly Experienced

Arkansas Department of Human Services Request for Adult Maltreatment Registry Information

Authorization

I authorize Department of Human Services/Adult Protective Services to release information from the Adult Maltreatment Central Registry in accordance with Ark. Code Ann. § 12-12-1717 to the following:

Certification

I further certify that the information provided on this form is true and correct.

Child Abuse Clearance Authorization

SERVICING THE FOLLOWING COUNTIES AND CITIES :

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