Application for Employment

Community Networks
LLC Application

Please carefully read and answer all questions. You will not be considered for employment if you fail to completely answer all the questions on this application. You may attach a résumé, but all questions must be answered.

Personal Data

First Name

Middle Name

Last Name

Street Address

City

State

Home Telephone Number

Business Telephone Number

Cellular Telephone Number

Date Available

Salary Desired

Date of Birth

Social Security No

Position Information

Position Applying For
Are you authorized to work in the U.S. on an unrestricted basis?	Yes	No
Have you ever been convicted of a felony? (Convictions will not necessarily disqualify an applicant for employment.)	Yes	No
Have you ever worked for this company?	Yes	No

QUALIFICATIONS

Please list any education/ training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs,and military training

	School Name	Degree	Address/City/State
School
School
Address/City/State

Applicable Skills

Proficiencies List any special skills or experience that you feel would help you in the position that you are applying for (leadership, organizations/teams, etc.)

References

lease list three professional references, with full name,address, phone number,and relationship. If you don’t have three professional references, then list personal, unrelated references.

Name	Address/City/State	Phone	Relationship/Company

Work History Start with your present or most recent employment and work back

Company

Start Date

End Date

Job Title

Supervisor’s Name

Phone Number

Address/City/State

Responsibilities

Reason for Leaving

Starting Salary

Ending Salary

May we contact your employer?

Yes No

Company

Start Date

End Date

Job Title

Supervisor’s Name

Phone Number

Address/City/State

Responsibilities

Reason for Leaving

Starting Salary

Ending Salary

May we contact your employer?

Yes No

Company

Start Date

End Date

Job Title

Supervisor’s Name

Phone Number

Address/City/State

Responsibilities

Reason for Leaving

Starting Salary

Ending Salary

May we contact your employer?

Yes No

Company

Start Date

End Date

Job Title

Supervisor’s Name

Phone Number

Address/City/State

Responsibilities

Reason for Leaving

Starting Salary

Ending Salary

May we contact your employer?

Yes No

I certify that my answers are true and complete to the best ofmy knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature

Date

Authorization To Perform A Background Cheсk

It is the policy of COMMUNITY NETWORKS, LLC and its subsidiaries, parents, successors, and affiliates (the COMMUNITY NETWORKS, LLC) to order a “consumer report” (commonly known as “background report” or “background check”) on all employees and/or contractors in connection with your employment application.

To the extent allowed by law, the background report may contain information concerning your character, general reputation, personal characteristics, mode of living, drug and alcohol test results, credit, and criminal history. To the extent allowed by law, information may be obtained from private and public record sources, including but not limited to, sanctions databases, court records, driving records, verification of employment and education history, licensing and credentials, military records, and police records.

I, authorize AGENCY, to perform a NC State Bureau of Investigation Criminal Background Check and a Department of Motor Vehicle Check.

Employee Name (Print)

Employee Signature

Date

Emergency / Medical Information

The information requested on this page is confidential and for emergency use only. In the event of an emergency, this information will be used by COMMUNITY NETWORKS, LLC staff and emergency personnel. Please be honest when complete this form.

First Name

Middle initial

Last Name

Home Address:

City

State

Zip Code

Telephone 1:

Telephone 2:

Date of Birth

In Case Of Emergency, Contact:

Name:

Relationship:

Street Address

City

State

Zip Code

Telephone 1:

Telephone 2:

Telephone 3:

Name:

Relationship:

Street Address

City

State

Zip Code

Telephone 1:

Telephone 2:

Telephone 3:

Health Information

Are you allergic to anything? If so, please list all allergies.

Are you taking any medication? If so, please list all medications.

Please note any other health concerns that we should be aware of.

Hepatitis B Declaration Form

Healthcare workers are at risk for the Hepatitis B virus (HBV) infection to the extent that they are exposed to blood or other fluids. The best protection against Hepatitis B is to regard all body fluids as potential infections. Standard precautions should be practiced and are recommended when treating clients with Hepatitis B. I have read and understood the Hepatitis B information sheet about Hepatitis B and Hepatitis B vaccination. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have read and been given the opportunity to be vaccinated with the Hepatitis B vaccine. Based on this information, I have made the following decision about receiving the vaccine. All Direct Care Providers are required to attend infection control in-severs that educate concerning standard precautions.

Please Check One:

I have previously completed the Hepatitis B Series of vaccinations.

Please list date of series vaccines

I wish to receive the Hepatitis B vaccine. I decline to receive the Hepatitis B vaccine. Please read, sign and date the declination statement page in addition to this Hepatitis B Consent/Declination Statement.

Declination Statement

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

In-Home Aide Job Description

The In-Home Aide provides hands-on assistance with ADL’s (activities of daily living) and IADL’s (instrumental activities of daily living) to clients in their home.

Qualifications:

I-year experience working in a home care setting
Must have a valid NC Driver’s License.
Personal means of transportation
Good interpersonal skills
Dependable
NA I or NA II (if applicable)

Job Duties:

Maintain the home in an optimum state of cleanliness and safety.
Provide light housekeeping tasks, including such duties as preparation of meals, laundry, shopping.
Provide hands on assistance with bathing, dressing, toileting, mobility, and eating.
Provide client with assistance with self-administration of medications. May assist with monitoring of blood pressure, blood sugar, weight, temperature, pulse, and respirations (if within scope of practicе and delegated by a RN)
Report to the Service Supervisor any change in condition, incidents or problems related to the client, immediately.
Report any unusual incidents or changes in the client’s behavior to the Service Supervisor.
Document accurately and maintain service records Perform other duties as assigned by the Service Supervisor.

I have read and understand the job description for In-Home Aide and agree to fulfill the position’s responsibilities to meet the defined standards.

Signature

Date

Application for Employment

Community Networks
LLC Application