Quality Care Health Services, LLC 809 Professional Pl Bldg A 103 Chesapeake, VA 23320 (757)4019871

APPLICATION FOR EMPLOYMENT Equal Opportunity Employer

We do not discriminate on the basis of age over 40, race, sex, color, religion, national origin, disability, or any other applicable
status protected by state or local law. It is our intention that all qualified applicant be given equal opportunity and that selection
decisions be based on job-related factors. Each question should be fully and accurately answered. No action can be taken on this
application until all questions have been answered. Use blank paper if you do not have enough room on this application. PLEASE
PRINT, except for signature on back of application. In reading and answering the following questions, be aware that none of the
questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Job Applied For: (PCA, RN, Administrative Assistant etc.) _________________

Today’s Date / ___ /___________

Are you seeking: Full-time _ Part-time_ Temporary _ When could you start work?

Present Street Address _______________________________________________

City __________________State _______Zip Code______

Are you 18 year of age or older? Yes _ No _ (If you are hired you may be required to submit proof of age.)

Social Security # __________________ If hired, can you furnish proof you are eligible to work in the
U.S.? Yes/No

Have you ever applied here before? Yes/No If yes, when?________________

Were you ever employed here? Yes /No If yes, when? __________

Have you ever been convicted of any law violation (except a minor traffic violation)? Yes/No

If yes, give details:

_____________________________________________________________________________________

(A “Yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for
which you are applying will also be considered.)

Are you now or do you expect to be engaged in any other business or employment? Yes/No If yes,
please explain:
_____________________________________________________________________________________

Driver’s License Number _________________ State of License: ______

Certificates/ Degrees _____________________________________________________

LIST NAME AND ADDRESS OF SCHOOLS

Quality Care Health Services, LLC 809 Professional Pl Bldg A 103 Chesapeake, VA 23320 (757)4019871

High School /GED __________________________________________________

College or University ___________________________Vocational or Technical _________________

List names of employers in consecutive order with present or last employer listed first. Account for all
periods of time including military service and any periods of unemployment. If self-employed, give firm
name and supply business references. PLEASE GIVE MONTH AND YEAR.

NAME OF EMPLOYER ________________________

JOB TITLE AND DUTIES__________________________________________________

ADDRESS______________________________________________________________

DATES OF EMPLOYMENT: FROM TO_________________________________________

CITY__________ STATE______________ZIP CODE_____________

PAY $__________SUPERVISOR___________________TELEPHONE______________________

REASON FOR LEAVING_____________________________________________________________

NAME OF EMPLOYER _______________________________________________

JOB TITLE AND DUTIES_________________________________________________________________

ADDRESS___________________________________________________________________________

DATES OF EMPLOYMENT: FROM TO____________

CITY_________________STATE____________ ZIP CODE_______________

PAY: ___________

SUPERVISOR___________________TELEPHONE______________________

REASON FOR LEAVING________________________________________________

PAY: START $___________ FINAL $_______________

SUPERVISOR_________________________________

TELEPHONE________________________________

Have you worked or attended school under any other name? Yes/No give name ___________________

Are you presently employed? Yes / No

Quality Care Health Services, LLC 809 Professional Pl Bldg A 103 Chesapeake, VA 23320 (757)4019871

If yes, may we contact your present employer? Yes / No

Have you ever been fired from a job or asked to resign? Yes / No

If yes, please explain :

_____________________________________________________________________________________

Give three references, not relatives or former employers.

Name Address Phone

_______________________ _______________________________ (____)_____-_______

_______________________ _______________________________ (____)_____-_______

_______________________ _______________________________ (____)_____-_______

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand
that any false information or omission may disqualify me from further consideration for employment
and may result in my dismissal if discovered at a later date.

Sworn Statement
Quality Care Health Services, LLC 809 Professional Pl Bldg A 103 Chesapeake, VA 23320 (757)4019871

Section 32.1-162.9 of the Code of Virginia requires that any person desiring to work at a licensed home
care organization shall provide the hiring facility with a sworn statement or affirmation disclosing any
criminal convictions or any pending criminal charges, whether within or outside the Commonwealth of
Virginia. The law prohibits licensed home care organizations from hiring any individuals convicted of a
barrier crime . However, applicants convicted of one misdemeanor barrier crime not involving abuse or
neglect may be hired if five years has elapsed since the conviction. Any person making false statement
on this form regarding any criminal offense shall be guilty of a Class 1 Misdemeanor. Further
dissemination of the information provided on this form is prohibited other than to the Commissioner's
representative or a federal or state authority or court as may be required to comply with an express
requirement of law for such further dissemination.

Last Name_______________ First _____________________ SSN: _____________________

Address: ___________________________________________________________________

Have you ever been convicted of a law violation? __________________

Are you subject to any criminal charges? ________________

If yes explain ______________________________________________________

I hereby affirm that the information provided on this form is true and complete and I agree and
understand that any falsification of information, regardless of time discovery, may cause forfeiture on my
part to any employment offered by this company.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT
OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I
UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE
TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE. I have read,
understand, and by my signature consent to these statements.

Signature Date ______/____________/______________

EMPLOYEE AVAILABILITY
Quality Care Health Services, LLC 809 Professional Pl Bldg A 103 Chesapeake, VA 23320 (757)4019871

Please provide the following information on your availability to work for QUALITY CARE HEALTH
SERVICES, LLC

Type of Transportation you have / will use for home visits: ______________________________

Do you have a problem working with a client who smokes? _No. _Yes

How many hours are you willing to work per week? _______________________

Which localities are you willing to work (circle those that apply, and/or write in additional locations):

CHESAPEAKE, SUFFOLK, PORTSMOUTH, NORFOLK, NEWPORT NEWS, VIRGINIA BEACH

LIST THE TIMES OF DAY YOU ARE AVAILABLE TO WORK UNDER THE DAY OF WEEK YOU ARE ALSO
AVAILABLE

SUN MON TUE WED THUR FRI SAT

Overnight Yes/No

Initials: ___________

I authorize the companies I worked for and/or the individuals listed above to release
information about me to QUALITY CARE HEALTH SERVICES, LLC for employment verification.

Applicant Signature __________________________

Applicant Signature Date____/_____/____________

* Any employee working with Quality Care Health Services cannot work with any company
during their scheduled shift, if it is known that you are working two jobs at the SAME TIME
will be TERMINATED. ____________________________ Employee signature