Delicate Care Adult Day Services (DCADS) is an Equal Opportunity Employer.

APPLICATION FOR EMPLOYMENT

NOTE: ALL APPLICANTS ARE SUBJECT TO A BACKGROUND CHECK Delicate Care Adult Day Services upholds a Smoke and Drug Free environment
The mission of Delicate Care Adult Day Services is provide a quality, distinctive, and affordable set of services to the elderly, caregivers, and developmentally challenged individuals in need of the services we offer to the residents of Bethany, East Haven, Hamden, New Haven, West Haven, Woodbridge, and surrounding areas.

_____________________________________________________________________________ Position applied for _________________________________Date of Application___________ Name_____________________________________________Social Security #______________ Last First Middle (Optional) Address ______________________________________________________________________ Street City State Zip Phone #( )___________Mobile/Daytime/Evening_______________E-Mail_____________ _____________________________________________________________________________
Have you been employed here before? Yes No If Yes give dates and position(s)________ Are you legally eligible for employment in this country? Yes No If hired, you will be required, within three (3) days, to show proof of identify and authorization for employment in the United States. You will also be required to sign a I-9 Form verifying, under oath, your employment authorization. Date available for work: ____/____/___ Hours desired: Full time Part time

Days

Evening

Temporary/Casual Nights

Any Weekends

Any

EDUCATION
School Elementary High School Business/ Trade School College Graduate School Name and Location of School Course of Study # of years Graduate? Degree or Diploma

Yes No Yes No Yes No Yes No Yes No

EMPLOYMENT
Please list most recent or present employment first Name of Company: Phone # ( ) Address: 1 Supervisors Name: Position held/Description of duties Dates employed: From: Starting wage: Reason for leaving:

To: Ending Wage:

Name of Company: Address:

2

Phone # (

Supervisors Name: Position held/Description of duties

Dates employed: From: Starting wage: Reason for leaving:

To: Ending Wage:

Name of Company: Address: Supervisors Name: Position held/Description of duties

Phone # (

Dates employed: From: Starting wage: Reason for leaving:

To: Ending Wage:

We may contact the employers listed above, unless you indicate those you would not like us to contact.

DO NOT CONTACT Employers Number(s)_______________________ ____Reason_________________________

Did you serve in U.S. Armed Forces? Yes No

MILITARY If Yes: What Branch?

Describe any special training received relevant to position applied for:

LICENSE/CERTIFICATION/SPECIAL SKILLS
Type of License License/Certification Number Expiration Date

CNA Certification Licensed Practical Nurse Registered Nurse Direct Care Professional Other___________________ Nursing and nursing assistant applicants only:Have you ever been subject to disciplinary action by a licensing
agency in any state, the District of Columbia, a United States possession or territory, or a foreign jurisdiction? Yes No If Yes, Explain _________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
I understand that Delicate Care Adult Day Services will make a thorough investigation that will include a confirmation of my entire work history, and the confirmation of all information included in this application. I authorize such an investigation and the giving and receiving of any information by the Agency. I am aware that I have a right to make a written request as to the nature and scope of this investigation. I release from liability any person giving or receiving any such information. In the event of my employment with Delicate Care Adult Day Services, I will abide by all rules and regulations as laid out in the

DCADS policy and procedure manual, or the communication distributed by the DCADS to all employees. I understand that if I am
appointed, my job with the Agency will be at will and may be terminated by the Agency, or me, at any ti me, for any reason, or for no reason. I understand that no documents or statements by the DCADS will represent a contract or employment that in any way limits the DCADS rights to terminate my employment at will. I also understand that the at will nat ure of my employment cannot be altered except by a formal written contract signed by the Administrator of Delicate Care Adult Day Care Services. I confirm that there are no misrepresentations, omissions, or falsifications in the foregoing statements and answers and that the responses given are true, complete, and accurate to the best of my knowledge and made in good faith. Without limiting the at will status of my employment, if I am hired, I understand that if any of the statements in this application are untrue; my employment will be terminated immediately. I understand that Federal law prohibits the DCADS from hiring or keeping an employee who has been found guilty of client abuse, neglect, or ill-treatment by a court of law, or who has had an adverse finding entered against him/her in the nurses aide registry. If it is exposed after being hired, that I have been untruthful about my history of patient abuse, neglect, or ill-treatment, I will be subject to immediate discharge. I authorize all educators, agencies, and employers listed in this application to furnish the DECADS with information regarding my education, employment history, or any other matter related to my application with the DECADS. I understand that this application remains current for 30 days. At the completion of that time, if I desire further consideration for employment, it will be necessary to fill out a new application. I understand that certain positions at DECADS may require the successful completion of a drug screen prior to the start of employment periodically according to the post-offer and random drug screen plan. I understand that this is an application for employment and that no employment contract is being offered. I further understand that if employed, such employment is for no definite period of time, and the DECADS can change wages, benefits, and conditions of employment at any time. I have read and understand the above:

CRIMINAL BACKGROUND: Signature of Applicant __________________________________ Date ____________________________

NOTE: THIS PORTION OF THE APPLICATION WILL ONLY BE REVIEWED BY MEMBERS OF THE ADMINISTRATION (OR PERSON(S) IN CHARGE OF EMPLOYMENT) AND ANYONE INVOLVED IN INTERVIEWING THE APPLICANT

Have you ever been convicted of a crime?

Yes________

No_______

If yes, please give information regarding the nature of the charge, the date and location of conviction and the final disposition of the case: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Applicants are not required to disclose the existence of an arrest, criminal charge or conviction for which records have been erased. The types of records subject to erasure under Connecticut laws are as follows: (a) (b) (c) (d) (e) a finding of delinquency or that a child was a member of a family with service needs; a sentence as a youthful offender; a criminal charge that was dismissed or nolled; a criminal charge for which the person was found not guilty; and a conviction for which the person received an absolute pardon.

Any applicant, whose criminal records were erased, will be considered to have never been arrested and may so declare under oath. I understand that the information provided above will not necessarily result in the rejection of my application, but that the nature of the information will be considered as it relates to the performance of the job duties in question and in light of the requirements of state and federal law. I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or employment agency policy and procedure. Applicants Signature: ________________________________ Date: ___________________

APPLICANT DO NOT WRITE ON THIS PAGE FOR EMPLOYERS USE ONLY

HR USE ONLY Pre Interview Screen Date ____________ Comments _________________________

INTERVIEWER NAME AND COMMENTS I N Essential duties explained; Can applicant perform? ____ Accommodation T E needed? Explain: R V I E W S

Person Contacted

Results

R E F E R E N C E C H E C K S

REFERENCE REQUEST

Company Name ____________________________________________________________________________ Supervisors Name__________________________________________________________________________ Address________________________________________________ Phone______________Fax____________ I have applied for employment with Delicate Care Home Health Services, and have listed you as a reference. Please provide to the following questions and return this form to Delicate Care Home Health Services. By this authorization, I hereby release you from any liability or action based upon the content of your answers. Thank you for your cooperation and assistance. Sincerely yours, _
Signature of Applicant Date

Applicants Name________________________________________ Social Security #____________________________ Dates in your employ: From____________To____________Ending Wage $_____________________per__________ Position Held: _____________________________________________________________________________________

Is the above information correct? Yes No. If not please state correct information_________________ _________________________________________________________________________________________ Why did applicant leave your employer? ________________________________________________________ Would you re-employ? Yes_______ No______ If no, why not? ______________________________________ Please rate applicant on the following characteristics: Poor Quality of work Quantity of work Attendance Dependability Cooperation Any additional Comments:____________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Fair Average Very Good Excellent

Signature ___________________________________________ Date__________________________________ PLEASE RETURN TO FAX # (203) 891-7412; or mail to: Delicate Care Home Health Services, 630 Dixwell Avenue, New Haven, CT 06511