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

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.) Do you have any other certifications or licenses? Yes No If so, please list them in the space provided below. 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, what days? We use an automated shift notification system, please enter the following information to be informed when new shifts become available. 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. Hillgrove Avenue La Grange, IL 60525 p. 708.869.8100 f. 708.869.8109 PrivateHomeCareServices.com Private Home Care Services, LLC

How did you hear about Private Home Care Services, 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 explain Employment History: Please list ALL PLACES OF EMPLOYMENT in chronological order, beginning with your current or most recent employer. Please request another reference page if needed. Job Title Address City, State, Zip Supervisor Reason for Leaving Employer

Phone Number Dates Employed

Job Title Address City, State, Zip Supervisor Reason for Leaving

Employer

Phone Number Dates Employed

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

 Job Title

Employer

Address City, State, Zip Supervisor Reason for Leaving

Phone Number Dates Employed

Job Title Address City, State, Zip Supervisor Reason for Leaving

Employer

Phone Number Dates Employed

Job Title Address City, State, Zip Supervisor Reason for Leaving

Employer

Phone Number Dates Employed

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

 References: 1. Name & Title 2. Name & Title Relationship Relationship Phone Number Phone Number

3. 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). It shows training information for certified nursing assistants (CNA) and other health care workers. Additionally, it displays administrative findings of abuse, neglect or misappropriations of property. It is maintained by the Department of Public Health. 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, nurse aides, personal care assistants, private duty nurse aides, day training personnel, or an individual working in any similar health- related occupation where he or she provides direct care (e.g., resident attendants, child care/habilitation aides/developmental disabilities aides, and psychiatric rehabilitation services aides) or has access to long-term care residents or the living quarters or financial, medical or personal records of long-term care residents. 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, medical or personal records of residents. Individuals with disqualifying convictions, as listed in the act, are prohibited from working in any of the above positions unless a waiver has been granted by the Department of Public Health. A health care employer must verify registry status of an individual applying for the above positions prior to employment. Verifications can be made by phone (217-785-5133), e-mail (DPH.HCWR@Illinois.gov), mail (Illinois Department of Public Health, Health Care Worker Registry, 525 W. Jefferson St., Fourth Floor, Springfield, IL 62761), or this Web site. I authorize Private Home Care Services, LLC to verify I am eligible to be employed based on the Illinois Health Care Worker Background Check Act. Signature Date

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

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. 1. A health care employer who makes a conditional offer of employment to an applicant who is not exempt under Section 955.130 of this Part shall check the Health Care Worker Registry for the date of the applicant's last UCIA criminal history records check. If more than 12 months have passed since the records check, the health care employer shall initiate or have initiated on its behalf a UCIA criminal history records check for that applicant. 2. An educational entity, other than a secondary school, conducting a nurse aide training program must initiate a UCIA criminal history records check prior to entry of an individual into the training program. 3. 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. 4. 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. 5. The request for a UCIA criminal history records check shall be made as prescribed by the Department of State Police. 6. A health care employer may conditionally employ an employee for up to three months pending the results of a UCIA criminal history records check. 7. 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, challenge the accuracy of the report, and request a waiver in accordance with this Part. 8. 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. 9. The health care employer shall develop policies concerning employment of individuals whose criminal history records checks indicate convictions for offenses that are not disqualifying. 10. If a student, applicant, 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, a fingerprint-based UCIA criminal history records check shall be conducted. 11. 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.
19 W. Hillgrove Avenue La Grange, IL 60525 p. 708.869.8100 f. 708.869.8109 PrivateHomeCareServices.com Private Home Care Services, LLC

I authorize Private Home Care Services to run a background check for the purpose of employment. 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, LLC permission to check all previous places of employment and references listed above. Signature Date

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

Applicant Authorization to Release Records (PLEASE PRINT) Complete Name Maiden / AKA

Number & Street City, State & Zip Code Previous Address (if less than 7 years at current City, 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. I understand that the information supplied by me can be utilized in conducting a background investigation which may include, but not be limited to, a consumer credit report, criminal history search, driving record history, workers compensation report, education / degree verification and verification of any information provided on application form. I hereby additionally authorize release of my educational record status. I release from liability all persons, companies and corporations supplying information as a result of this investigation. I further release and indemnify the above named and InfoTrack Information Services, Inc., against any liability that might result from conducting these investigations. Date________________________________ Signature of Applicant__________________________________

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