Home Provider Application

Your Name*
First Last
Your Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Mailing Address (if different than home address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Home Phone
Your Work Phone
Your Cell Phone*
Your Email Address*
Enter Email Confirm Email
How long have you lived at current residence (years & months)?*
Do you:*
- Own
- Rent
If you rent, may we contact your landlord?
- Yes
- No
Your Landlord's Name
First Last
Landlord's Address
Street Address City State / Province / Region ZIP / Postal Code
Landlord's Phone
Are you employed?*
- Yes
- No
If you answered yes, where are you currently employed?
Please check all that apply:
- I am currently employed part-time
- I am currently employed full-time
- My current job is temporary
Have you ever provided respite, emergency or other specialized care?*
- Yes
- No
If you answered yes, please explain:
Employment History
Please list names, addresses and phone numbers of your employers beginning with your most recent. Please fill out the form as completely as possible.
1
Employer's Name
Employer's Phone
Supervisor's Name
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Position
Duties
Reason for leaving?
May we contact this employer?
- Yes
- No
2
Employer's Name
Employer's Phone
Supervisor's Name
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Position
Duties
Reason for leaving?
May we contact this employer?
- Yes
- No
3
Employer's Name
Employer's Phone
Supervisor's Name
First Last
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Position
Duties
Reason for leaving?
May we contact this employer?
- Yes
- No
References
Please list 2 personal references AND 2 professional references (preferably non-relatives).
Personal Reference 1 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Relationship
Personal Reference 2 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Relationship
Professional Reference 1 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Relationship
Professional Reference 2 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
Relationship
Education
Please indicate education level achieved, and provide details below:
- High School Diploma or equivalent
- Associate's Degree
- Bachelor's Degree
- Post Graduate Degree
Trade school(s) attended:
License(s) held:
Certificate(s) earned:
College(s) attended:
Degree(s) achieved:
Other training:
Background Information
Have you or anyone in your household ever been convicted of a felony or a misdemeanor? [Please note that upon submission of this Application, the Applicant, as well as anyone living in the household above the age of 18, is required to submit to a Criminal Records Background check.]
- Yes
- No
If you answered yes, please provide details about the conviction(s) and include the date(s) of the violation(s).
Do you have any driving violations on your driving record? [Please note that upon submission of this Application, the Applicant is required to submit to Driving Record Check.]
- Yes
- No
If you answered yes, please provide details and date(s) of violation(s).
Have you ever been accused in a founded case of abuse, neglect or exploitation by The Department of Elderly and Adult Services, an Area Agency, or a Vendor Agency?
- Yes
- No
If you answered yes, please specify the date(s) and specific parties involved as well as the circumstances surrounding the case(s).
Please provide us with a complete list of ALL individuals living in your home who are 18 or older. Please include yourself as well.
Name
First Last
Date of birth
MM slash DD slash YYYY
Relationship
Name
First Last
Date of birth
MM slash DD slash YYYY
Relationship
Name
First Last
Date of birth
MM slash DD slash YYYY
Relationship
Name
First Last
Date of birth
MM slash DD slash YYYY
Relationship
Name
First Last
Date of birth
MM slash DD slash YYYY
Relationship
Name
First Last
Date of birth
MM slash DD slash YYYY
Relationship
About You and Your Home
1. How many sets of stairs are there in your home (inside and out)?
2. How many entrances/exits are there in your home?
3. Is your home handicapped accessible?
- Yes
- No
4. How many rooms are there in your home?
5. Please list all pets/animals in your home.
6. Do you (or anyone residing in your household) smoke?
- Yes
- No
7. If you answered yes to question 6, does anyone smoke inside the home?
- Yes
- No
8. Do you (or anyone residing in your household) drink alcohol?
- Yes
- No
9. If you answered yes to question 8, where in the home is the alcohol stored?
10. Do you (or does anyone in your household) own or store any firearms in your home?
- Yes
- No
11. If you answered yes to question 10, where in the home are the firearms stored?
12. Do you have any children (or anyone) living in your home who is under the age of 18?
- Yes
- No
13. If you answered yes to question 12, please provide their name(s), date(s) of birth, and describe their relationship(s) to you.
14. Do you have any religious beliefs that would prevent you from allowing a potential client to celebrate specific holidays, eat certain foods, etc.?
- Yes
- No
15. If you answered yes to question 14, please explain below.
16. If there are there any circumstances in your past or present life that may impact on your ability to provide services, please explain below.
17. If you have any experience working with individuals with disabilities, please describe below.
18. What length of time can you commit to being a home provider?
19. Please explain what 'confidentiality' means to you.
20. Do you see yourself as a caregiver, a coach or a mentor? Please explain.
Please read the following statements carefully, and acknowledge that you have done so.
As of November 6, 1986, the Immigration Act requires that all employers hire only U.S. citizens and aliens lawfully authorized to work in the United States. Any offer of employment will be contingent upon you providing Community Partners with the documentation required by the INS to establish that you meet these requirements.
I hereby affirm that the information given by me on this application and all supporting documents are complete and accurate. I understand that any falsification or omission on this application or supporting documents, or otherwise providing false information to Community Partners, will be considered sufficient basis for dismissal, no matter when the falsification or omission is discovered.
- I acknowledge and affirm the above statement as my own.
- I do not acknowledge nor affirm the above statement.
I hereby authorize Community Partners to thoroughly investigate my background, references, employment record and other matters related to my suitability for employment as a Home Provider, including the successful completion of a Criminal Record Check, Driver's Record Check, and post-offer, pre-employment physical exam and TB test as a condition of employment.
- I acknowledge and affirm the above statement as my own.
- I do not acknowledge nor affirm the above statement.
I hereby authorize Community Partners to obtain consumer reports about me and to consider the consumer reports when making decisions regarding whether to offer me employment, when deciding whether to continue my employment (if I am hired), and when making other employment-related decisions directly affecting me. I understand that the consumer reports may bear on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. I release Community Partners from any claims or liabilities of any kind resulting from its obtaining and using any such consumer reports.
- I acknowledge and affirm the above statement as my own.
- I do not acknowledge nor affirm the above statement.
If I am hired, I agree to abide by all of the employment policies of Community Partners, and agree that my employment and compensation can be terminated with or without cause, and without notice at any time, at the option of Community Partners or myself. I understand that, unless modified in a written agreement signed by both myself and the Director of Human Resources and the Chief Executive Officer or Chief Financial Officer of Community Partners, no representative of Community Partners has the authority to make any agreement for employment for a specified time or to make any other agreement contrary to the foregoing.
- I acknowledge and affirm the above statement as my own.
- I do not acknowledge nor affirm the above statement.
Electronic Signature
* By typing your name and initials below you acknowledge that you have read and agree to the terms and statements set forth above in the Community Partners Employment Application. Typing your name and initials below constitutes a legally binding electronic signature.
Print your name as you would if you were signing a document:*
Enter your initials below:*
Upload any Supporting Documentation
You may upload any supporting documentation (cover letter, resume, references, etc.) here:
Max. file size: 2 MB.

Home Provider Application

Employment History

1

2

3

References

Education

Background Information

Please provide us with a complete list of ALL individuals living in your home who are 18 or older. Please include yourself as well.

About You and Your Home

Please read the following statements carefully, and acknowledge that you have done so.

Electronic Signature

Upload any Supporting Documentation