HHA Application

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Your Personal Information

Your Name(Required)

First Middle Last

Your Email Address(Required)

Enter Email Confirm Email

Position You're Applying For(Required)

HHA

DDS

Driver

Other

Hours Available(Required)

Full Time

Part Time Relief / PRN

Weekdays

Weekends

Overnight

Your Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Education

High School(Required)

Please tell us about your education.

School

Name & Location

Degree

Major

Date Awarded

College

Please tell us about your education.

School

Name & Location

Degree

Major

Date Awarded

Trade or Other Education

Please tell us about your education.

School

Name & Location

Degree

Major

Date Awarded

Do you have a current HHA certificate?(Required)

Please answer

If so, what is you NPI Number?(Required)

Certificates & Licenses

List any special qualifications and skills you have, or specific courses you have completed related to the requirements for the position (CPR, First Aid, Etc.)

Please list any other names you have used in employment and/or education records.

Have you ever been subject to an allegation of abuse or neglet?(Required)

Yes

If yes, please explain:

Have you ever been convicetd as an adult for a law vialotion?(Required)

Yes

If yes, please explain:

Explain by giving full details and dates. (Convictions will not automatically disqualify you from consideration)

Are you eligible to work for any employer in the United States?(Required)

Yes

Have you ever been employed by or previously applied for a position with ICS?(Required)

Yes

Criminal Background Check

Driver's License(Required)

Valid driver’s license is only required for driving positions

Yes

State of Issue(Required)

Exp. Date(Required)

License Number(Required)

Social Security(Required)

Date of Birth(Required)

Prior conviction?(Required)

Have you ever been convicted of a law violation(s) but excluding offenses committed before your 18th birthday, that were finally adjudicated in a juvenile or under youth offender law?

Yes

If yes, list all and explain

Are you the subject of any pending criminal charges?(Required)

Yes

If yes, please explain

Background Check Consent(Required)

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

I give consent to ICS, Inc to perform a background check on me.

Experience

Your Previous Employers(Required)

Please list your previous employers, the dates you worked and the position you held

Employer

Phone

Position

Start Date

End Date

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

Phone

Position

Start Date

End Date

Your Previous Employers

Please list your previous employers, the dates you worked and the position you held

Employer

Phone

Position

Start Date

End Date

Reference Check Consent(Required)

I acknowledge that I have completed an application with Integrated Community Services, Inc and Authorize the release of any information from former employer and/ or school.

I agree