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Private  Home  Care  Services,  LLC   19  W.  Hillgrove  Avenue   La  Grange,  IL  60525   p.  708.869.8100   f.  708.

869.8109   info@privatehomecareservices.com   www.privatehomecareservices.com     APPLICATION  FOR  EMPLOYMENT     INSTRUCTIONS:  Please  read  carefully.  Every  item  on  this  form  must  be  answered  to  the  best  of  your   ability.  Please  print  and  use  a  pen.     Your  qualifications  will  be  carefully  reviewed  and  you  will  be  given  thorough  consideration  for  any   suitable  opening.  Upon  employment,  this  application  will  become  part  of  your  personnel  record.   Illinois  is  an  “At-­‐Will  State”  meaning  that  the  employer  or  employee  can  terminate  employment  at   any  time  and  either  party  needs  no  reason  for  termination.  You  are  not  required  to  supply  any   information  that  is  prohibited  by  federal,  state  or  local  law.     Private  Home  Care  Services,  LLC  does  not  discriminate  on  the  basis  of  race,  color,  religion,  sex,   national  origin,  citizenship,  age,  marital  status  or  disability.  You  may  request  assistance  in  completing   this  application.   Last  Name:   First  Name:   Social  Security  Number:       MI:   Date  of  Birth:      

Phone  Number:______________________________________Drivers  License  Number:_________________________________________   Race/Ethnicity  (optional,  not  used  for  employment  decision  making  purposes):___________________________________   Email  address:__________________________________________________________________________     Address:       Address:   City:     Mailing  Address:  (if  different  from  above)   Address:   City:   Emergency  contact:   Relation:         State:             Zip:               State:       Zip:  

     

Phone  Number:    

Have  you  ever  worked  for  or  applied  for  work  with  Private  Home  Care  Services,  LLC  previously?         Yes        No    

19  W.  Hillgrove  Avenue  •  La  Grange,  IL  60525  •  p.  708.869.8100  •  f.  708.869.8109  •  PrivateHomeCareServices.com   ©  Private  Home  Care  Services,  LLC  

 Hillgrove  Avenue  •  La  Grange.  708.869.  please  enter  the  following  information  to  be  informed   when  new  shifts  become  available.  IL  60525  •  p.8100  •  f.     I  am  able  to  receive  text  messages:     YES_____     NO______     Phone  Number  to  receive  text  messages:  _______________________________________________________     I  am  able  to  receive  email  messages:     YES_____     NO______     Email  address  to  receive  email  messages:  ______________________________________________________     I  cannot  receive  text  or  email  messages:  ________________________________________________________         19  W.)   Do  you  have  any  other  certifications  or  licenses?        Yes        No          If  so.  what  days?     We  use  an  automated  shift  notification  system.                   Type  of  employment  sought:          Regular  Full-­‐time          Regular  Part-­‐time          Temporary          As   Needed   When  are  you  available  for  work?            Days            Nights            Weekends            Holidays   Indicate  hours  you  are  available  to  work  on  the  following  days:   Monday   _____to_____   Tuesday   _____to_____   Wednesday   _____to_____   Thursday   _____to_____   Friday   _____to_____   Saturday   _____to_____   Sunday   _____to_____                   Are  you  available  for  live-­‐ins?   If  so.com   ©  Private  Home  Care  Services.869.  please  list  them  in  the  space   provided  below.8109  •  PrivateHomeCareServices.  LLC       .  708.Have  you  had  any  experience  related  to  caregiving?        Yes        No       Nursing  Home          Family          Friend          Other   Are  you  currently  certified  as  a  CNA?        Yes        No          (Certification  is  not  required  for  employment   with  our  company.

 708.  IL  60525  •  p.  please  explain             Employment  History:  Please  list  ALL  PLACES  OF  EMPLOYMENT  in  chronological  order.How  did  you  hear  about  Private  Home  Care  Services.  State.  LLC   .  LLC?         Have  you  ever  been  arrested  and/or  convicted  of  a  misdemeanor  of  felony  other  than  a  minor  traffic   violation?      Yes        No   If  yes.  Please  request  another  reference  page  if  needed.869.869.  708.  State.  beginning   with  your  current  or  most  recent  employer.8109  •  PrivateHomeCareServices.  Zip     Supervisor     Reason  for  Leaving             Employer                                     Phone  Number   Dates  Employed                 Job  Title     Address     City.8100  •  f.  Hillgrove  Avenue  •  La  Grange.     Job  Title     Address     City.com   ©  Private  Home  Care  Services.  Zip     Supervisor     Reason  for  Leaving           Employer                         Phone  Number   Dates  Employed               19  W.

 Hillgrove  Avenue  •  La  Grange.8100  •  f.  Zip     Supervisor     Reason  for  Leaving             Employer                         Phone  Number   Dates  Employed                   Job  Title     Address     City.  Zip     Supervisor     Reason  for  Leaving               Employer                         Phone  Number   Dates  Employed               19  W.869.  708.8109  •  PrivateHomeCareServices.  LLC   .869.  State.   Job  Title           Employer       Address     City.com   ©  Private  Home  Care  Services.  State.  708.  Zip     Supervisor     Reason  for  Leaving                         Phone  Number   Dates  Employed                   Job  Title     Address     City.  State.  IL  60525  •  p.

 are  prohibited  from  working  in  any  of  the  above  positions  unless  a  waiver  has   been  granted  by  the  Department  of  Public  Health.8100  •  f.  Individuals  with  disqualifying  convictions.  or  this  Web   site.       Signature                       Date       19  W.  A  health  care  employer  must  verify  registry  status   of  an  individual  applying  for  the  above  positions  prior  to  employment.  e-­‐mail  (DPH..  it  displays   administrative  findings  of  abuse.HCWR@Illinois.  708.       The  Health  Care  Worker  Background  Check  Act  applies  to  all  unlicensed  individuals  employed  or   retained  by  a  health  care  employer  as  home  health  care  aides.  mail  (Illinois  Department  of  Public  Health.  IL  62761).  or  an  individual  working  in  any  similar  health-­‐ related  occupation  where  he  or  she  provides  direct  care  (e.       References:   1.  525  W.  Springfield.  child   care/habilitation  aides/developmental  disabilities  aides.       Name  &  Title     2.8109  •  PrivateHomeCareServices.  LLC   .  resident  attendants.g.  nurse  aides.com   ©  Private  Home  Care  Services.  Additionally.       I  authorize  Private  Home  Care  Services.  personal  care  assistants.   private  duty  nurse  aides.  IL  60525  •  p.  medical  or  personal  records  of  residents.  neglect  or  misappropriations  of  property.gov).  Verifications  can  be  made  by   phone  (217-­‐785-­‐5133).  medical  or   personal  records  of  long-­‐term  care  residents.  It  is  maintained  by  the   Department  of  Public  Health.  LLC  to  verify  I  am  eligible  to  be  employed  based  on  the   Illinois  Health  Care  Worker  Background  Check  Act.  Hillgrove  Avenue  •  La  Grange.  It  shows  training  information  for   certified  nursing  assistants  (CNA)  and  other  health  care  workers.   as  listed  in  the  act.  Fourth  Floor.   Health  Care  Worker  Registry.           Name  &  Title   Relationship   Phone  Number     Illinois  Health  Care  Worker  Background  Check  Act:     The  Health  Care  Worker  Registry  lists  individuals  with  a  background  check  conducted  pursuant  to   the  Health  Care  Worker  Background  Check  Act  (225  ILCS  46).  and  psychiatric  rehabilitation  services   aides)  or  has  access  to  long-­‐term  care  residents  or  the  living  quarters  or  financial.       Name  &  Title     Relationship     Relationship     Phone  Number     Phone  Number         3.  It  also  applies  to  all  employees  of  licensed  or  certified   long-­‐term  care  facilities  who  have  or  may  have  contact  with  residents  or  access  to  the  living  quarters   or  the  financial.  708.869.  Jefferson  St..869.  day  training  personnel.

 a  fingerprint-­‐based  UCIA  criminal  history  records  check  shall  be  conducted.     9.com   ©  Private  Home  Care  Services. The  health  care  employer  or  educational  entity  shall  transmit  all  necessary  information  and   fees  to  the  Department  State  Police  within  10  working  days  after  receipt  of  the  authorization   for  a  UCIA  criminal  history  records  check.     3.UCIA  Criminal  History  Records  Check       Private  Home  Care  Services  will  conduct  a  check  of  criminal  history  information  conducted  by  the   Department  of  State  Police  in  accordance  with  the  Uniform  Conviction  Information  Act.  conducting  a  nurse  aide  training   program  must  initiate  a  UCIA  criminal  history  records  check  prior  to  entry  of  an  individual   into  the  training  program.       7. An  educational  entity.         1.         8.869.  or  employee  challenges  the  results  of  the  non-­‐fingerprint-­‐based  UCIA   criminal  history  records  check  or  if  a  non-­‐fingerprint-­‐based  UCIA  criminal  history  records   check  does  not  identify  the  individual's  criminal  history  records  due  to  multiple  common   names.  and  request  a  waiver  in  accordance  with  this  Part. If  a  student.8100  •  f.  other  than  a  secondary  school. The  health  care  employer  shall  develop  policies  concerning  employment  of  individuals   whose  criminal  history  records  checks  indicate  convictions  for  offenses  that  are  not   disqualifying.130  of  this  Part  shall  check  the  Health  Care  Worker  Registry   for  the  date  of  the  applicant's  last  UCIA  criminal  history  records  check.  LLC   . A  health  care  employer  may  conditionally  employ  an  employee  for  up  to  three  months   pending  the  results  of  a  UCIA  criminal  history  records  check.     11.8109  •  PrivateHomeCareServices.  challenge  the  accuracy   of  the  report.  IL  60525  •  p. The  health  care  employer  shall  inform  the  applicant  or  employee  of  his  or  her  right  to  obtain   a  copy  of  the  criminal  records  report  from  the  health  care  employer. A  health  care  employer  who  makes  a  conditional  offer  of  employment  to  an  applicant  who  is   not  exempt  under  Section  955.       2.  708.  the  health  care  employer  shall  initiate  or  have   initiated  on  its  behalf  a  UCIA  criminal  history  records  check  for  that  applicant. The  fingerprint-­‐based  UCIA  criminal  history  records  check  will  not  be  accepted  for  a  waiver   application  after  implementation  of  the  process  of  initiating  a  fingerprint-­‐based  criminal   history  records  check  through  the  web  application.     10.  applicant. The  request  for  a  UCIA  criminal  history  records  check  shall  be  made  as  prescribed  by  the   Department  of  State  Police. The  health  care  employer  shall  send  a  copy  of  the  results  of  the  UCIA  criminal  history   records  check  for  any  employee  to  the  Health  Care  Worker  Registry.     5.  708. The  health  care  employer  may  accept  the  results  of  an  authentic  UCIA  criminal  history   records  check  that  has  been  conducted  within  the  last  12  months  rather  than  initiating  a   check  as  required  in  subsection  (a)  of  this  Section.       4.       6.    If  more  than  12   months  have  passed  since  the  records  check.869.     19  W.  Hillgrove  Avenue  •  La  Grange.

 LLC   .  708.8109  •  PrivateHomeCareServices.     Based  on  the             Signature               Date     I  certify  that  all  information  is  true  and  correct  to  the  best  of  my  knowledge  and  give  Private   Home  Care  Services.  708.       Signature         Date                                                                   19  W.com   ©  Private  Home  Care  Services.869.  Hillgrove  Avenue  •  La  Grange.I  authorize  Private  Home  Care  Services  to  run  a  background  check  for  the  purpose  of  employment.  IL  60525  •  p.869.  LLC  permission  to  check  all  previous  places  of  employment  and   references  listed  above.8100  •  f.

    I   release   from   liability   all   persons.  State  &  Zip  Code   address)   Previous  Address  (if  less  than  7  years  at  above  address)   City.  State  &  Zip  Code   Social  Security  Number     Drivers  License  Number   Date  of  Birth     State  Issued       Authorization   I  hereby  consent  and  authorize  PRIVATE  HOME  CARE  SERVICES  to  secure  information  pertaining   to  my  character  and  background.   a   consumer   credit   report.  State  &  Zip  Code       Previous   Address   (if   less   than   7   years   at   current   City.869.   I   further   release   and   indemnify   the   above   named   and   InfoTrack   Information   Services.  IL  60525  •  p.8109  •  PrivateHomeCareServices.  LLC   .  708.     Date________________________________  Signature  of  Applicant__________________________________     19  W.  I  understand  that  the  information  supplied  by  me  can  be  utilized   in   conducting   a   background   investigation   which   may   include.  I   hereby   additionally   authorize   release   of   my   educational   record   status.Applicant  Authorization  to  Release  Records     (PLEASE  PRINT)   Complete  Name   Maiden  /  AKA   Number  &  Street   City.8100  •  f.   education  /  degree  verification  and  verification  of  any  information  provided  on  application  form.   driving   record   history.   Inc.   companies   and   corporations   supplying   information   as   a   result   of   this   investigation.   criminal   history   search.   but   not   be   limited   to.869.  708.   against   any  liability  that  might  result  from  conducting  these  investigations.  Hillgrove  Avenue  •  La  Grange.com   ©  Private  Home  Care  Services..   worker’s   compensation   report.