DISCLOSURE: All persons who provide direct care must disclose all criminal convictions, findings of guilt, pleas of guilty, and pleas of no contest except those including minor traffic offenses. (Minor traffic offenses include speeding & no-moving violations) Failure to make disclosure may disqualify you as an applicant or result in an employee’s termination. Do you have a disclosure? "YES" "NO" (circle one) If yes, describe:__________________________________________________________________
I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date. I understand that, if employed, my employment is not guaranteed for any term and is “at will”, which means that either I or At Home Help, LLC dba Comfort Keepers can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. No representative of companies other than the president is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the president. am employed, I agree to comply with and be bound by the safety and health rules, policies and regulations, and rules of conduct of At Home Help, LLC dba Comfort Keepers Please review and sign attached Job Description. This application will remain on active file for 60 days. If I am hired within this period, this form will be transferred to my individual personnel file. If I am not hired or have not heard from this employer within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job. If required, I agree to a drug testing prior and during employment or for post accident occurrences.
I give the employer and/or its’ agents, including consumer reporting bureaus, the consent to pre-employment criminal record check, closed records check and to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but is not limited to, credit reports, criminal conviction records, motor vehicle driving records and previous employment history. Further, I hereby release from liability and hold harmless this employer, its’ representatives, all persons and organizations/companies for furnishing such information. In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required. The employer, At Home Help LLC dba Comfort Keepers. is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application are used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. NOTICE: This is to inform you that as part of processing your employment application, we may obtain a consumer report and/or an investigative report which includes information as to your character, general reputation, personal characteristics and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights under the Fair Credit Reporting Act.”
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature of Applicant:_______________________________________________________________ Date:________________________________
Drug and Alcohol Consent Form and At Home Help LLC dba Comfort Keepers 61 Doctor's Park Drive Cape Girardeau, Mo 63703
The signing of this Consent Form, agreement to and cooperation of this policy, is required by all persons as a condition of employment. Employer is committed to protecting the safety, health and wellbeing of all employee and other individuals in our workplace. At Home Help LLC dba Comfort Keepers is a drug and alcohol-free workplace. As outlined in the company drug free workplace policy this company conducts random drug testing on all employees before hire and during employment. While employed your name will always be in the random pool. You can be chosen more than once for a random drug and/or alcohol test. It is At Home Help LLC dba Comfort Keepers, policy not to continue employment of anyone who tests positive for any illegal substance and/or drugs in their system regardless to the frequency or amount that they may have used. Medications legally prescribed are excluded.
All employees may be required, as permitted by federal and state laws, to undergo a drug test for pre-employment purposes, random testing or for cause which is due to reasonable suspicion of At Home Help LLC dba Comfort Keepers management. Employees may also be required to undergo alcohol screening when there is a suspicion of on-the-job impairment. I understand that I may be required to submit a urine sample for chemical analysis and that this analysis will be performed by qualified personnel. I freely consent and volunteer to this request for a specimen of urine. I hereby release At Home Help LLC dba Comfort Keepers, the medical provider and the laboratory performing the analysis including their employees and/or agents, from any liability whatsoever arising from this request to furnish my urine specimen, the testing of this specimen and the decisions made concerning my employment based upon the results of the analysis. I understand that anyone who refuses to take or who fails to pass a drug-screening test will not be qualified for employment by At Home Help LLC dba Comfort Keepers. I have read this policy, understand it and agree to the testing as part of the terms and conditions of my employment. Upon receipt of this notification, you may have to provide a valid urine sample for testing or participate in the Alcohol Breath Test. If you do not provide a valid urine specimen within 2 hours of notification or by the end of the Business day, it will be considered a refusal to test resulting in immediate termination. A refusal to either test, a tampered with or an adulterated specimen will result in immediate termination. A confirmed positive drug and/or alcohol test will result in the Company disciplinary action, as outlined in the Employment Manual.
I hereby acknowledge receipt of At Home Help LLC dba Comfort Keepers Inc. Drug-Free Workplace Policy regarding drugs and alcohol. I have read and understand this policy. I understand that the refusal to submit to any drug testing required by this policy or a positive test result is grounds for disciplinary action up to and including termination. Furthermore, I authorize the release of the test results to my employer, and/or on post-accident tests, the Company’s workers compensation insurance carrier and understand that refusal to release these results is grounds for disciplinary action up to and including termination. I understand that if I test positive for alcohol or drugs including, but not limited to, inactive components or metabolites associated with the use of such drugs following an on the job accident, I may be ineligible for workers compensation benefits or have benefits reduced by 50 percent as allowed by Missouri law.
I recognize that the Company’s policy on drugs and alcohol does not constitute an expressed or implied contract of employment. As a condition of continued employment, employees must sign the attached consent form and comply with the policy. You will be notified of your test results only if it is positive or adulterated. You will not be notified if your results are negative. All drug and/or alcohol test results are confidential.
Employee Acknowledgement of receipt and Testing: __________________ (Signature) OR
Employee Refusal To Test: _______________________(Signature)
CONSENT TO RECORDING
I am an applicant/employee or have another association with At Home Help LLC dba Comfort Keepers ® #157 & At Home Help, LLC. In consideration for and as a condition of my being hired or retained by Franchisee or for Franchisee’s continuing that association with me, I acknowledge and agree that my business conversations on the telephone lines and/or cell phones relating to Franchisee’s business may be recorded by Company and/or third parties in connection with Franchisee’s business operations. I understand, and intend, that Franchisee and any such third parties may rely on this consent.
Signature___________________________________________________________________________________ Date: ______________
CONFLICT OF INTEREST CERTIFICATION
I, _________________________________________ (name), understand that At Home Help LLC dba Comfort Keepers takes seriously its integrity and wants to maintain its reputation in all business interactions with clients, customers and vendors. I am NOT aware of any potential or actual conflict of interest. YES/NO I AM aware of a potential or actual conflict of interest. YES/NO
In accordance with such requirements and pursuant to the At Home Help LLC dba Comfort Keepers Conflict of Interest Policy, I hereby certify that I, members of my family, or any entity in which I or members of my family have an ownership interest, participate in the following interests, activities, transactions or have received the following substantial gifts which may be or appear to be a conflict of interest (if any). Full disclosure of any situation about which you have any doubt should be made so as to permit an impartial and objective determination of your possible Conflict of Interest. Such disclosure relates not only to yourself, but also to your family and any entity in which you or a family member has an ownership interest. I disclose the following:
Signature: __________________________________________________________________________ Date: _______________
