Employment Date DD dot MM dot YYYY Application InformationName(Required) First Last Middle Initial Address(Required) Street Address Apartment/Unit Number City State ZIp Code PhoneEmail(Required) Date(Required) MM slash DD slash YYYY Desired Salary(Required) Position Applied For(Required) Are You a Citizen of the United States? Yes No Have you ever worked for this Company?(Required) Yes No Have you ever been convicted of a felony?(Required) Yes No EducationHigh School Address From MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate? Yes No Diploma College Address From MM slash DD slash YYYY To MM slash DD slash YYYY Did you graduate? Yes No Diploma ReferencesPlease list three professional references.Full Name Relationship Company Phone Address Full Name Relationship Company Phone Address Full Name Relationship Company Phone Address Previous EmploymentCompany Phone Address Supervisor Supervisor Job Title Starting Salary Ending Salary ResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason For LeavingMay we contact your previous Supervisor for a reference? Yes No Company Phone Address Supervisor Job Title Starting Salary Ending Salary ResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason For LeavingMay we contact your previous Supervisor for a reference? Yes No Company Phone Address Supervisor Job Title Starting Salary Ending Salary ResponsibilitiesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Reason For LeavingMay we contact your previous Supervisor for a reference? Yes No Military ServiceBranch From MM slash DD slash YYYY To MM slash DD slash YYYY Rank at Discharge Type at Discharge If other than honorable, explainDisclaimer and SignatureDisclaimer 2 If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Disclaimer 1 I certify that my answers are true and complete to the best of my knowledge.Name Date MM slash DD slash YYYY Employee Reference SheetI , authorize the release of my work history and job reference to Azara Home Health.Name Employee Completes BelowEmployer Name Employee Date of Hire Employee Date of Termination Employee Date of Hire Full-Time Seasonal PRN Part-Time Temporary Eligible for Rehire Yes No Work-Performance Excellent Good Fair Poor Attendance Excellent Good Fair Poor CommentsEmployer Name and Title Azara Home Health Care Representative Name Please return via e-mail or fax: E-mail: Info@azarahomehealth.com Fax: 316-665-7255Kansas 3rd Party Consent FormI hereby certify that my name isName(Required) First Name Middle Initial Last Name Address(Required) Street Address City State ZIp Code Telephone Number(Required)Driver's License Number Tag Number Vehicle Identification Number Consent I hereby authorize Azara Home Health Care obtain my vehicle registration and/or driver's license record information including my personal informationon those records.Name(Required) Date MM slash DD slash YYYY Background Check Disclosure and AuthorizationPursuant to the federal Fair Credit Reporting Act, I hereby authorize Azara Home Health Care and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion,reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; birth records; motor vehicle records, Including traffic citations and registration; and any other public records.I , authorize the complete release of these records or data pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish Azara Home Health Care or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.Consent I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer's rights will be provided to me.Name(Required) Date MM slash DD slash YYYY PLEASE ATTACH THE FOLLOWING BEFORE TURNING IN YOUR APPLICATION:Copy of your ID/Drivers LicenseMax. file size: 100 MB.CAPTCHA
