Employee Application

Download and fill the form below and attach it in the last step for you to qualify.

Personal Information

First Name*

Middle Name

Last Name*

Other names you have used (If any)

Social Security #*

Street*

City*

State*

Zip*

Home Phone #*

Cell Phone #*

Email Address*

Emergency Contact Name*

Emergency Contact Phone #*

Emergency Contact Relationship*

How did you hear about this position?*

Referred By*

Are you at least 18 years of age?*

Are you legally entitled to work in the United States?*

U.S. Military or Naval Service

Rank

Present Membership in National Guard or Reserves?*

Employment Desired

Position*

Other Position

Have you passed Competency Testing?*

Do you have a Certificate?*

Do you have a current Driver’s License?*

Do you currently have a car?*

Have you ever applied to this Company before?

Where?

When?

Professional Licenses, Certification, and Registrations

Do you have any professional licenses, certifications and/or registrations?*

License/Certificate/Registration #:

Type

State Issued

Date Expires

Status

References

Give below the names of three work related references

Reference Details 1

Name

Address

Company/Position

Phone

Reference Details 2

Name

Address

Company/Position

Phone

Reference Details 3

Name

Address

Company/Position

Phone

Education

Highschool

Name and Location of School*

Years Attended

Graduated

Degree/Certification

College 1 Details

Name and Location of School

Years Attended

Graduated

Degree/Certification

College 2 Details

Name and Location of School

Years Attended

Graduated

Degree/Certification

Additional Training

Employment History

List a complete history of employment for the last five years, starting with the most recent. Attach additional pages if necessary.

Employment History 1

Date Month and Year

From

Name and Address of Employer Supervisor's Name

May we contact?

Salary

Position

Reason for leaving

Employment History 2

Date Month and Year

From

Name and Address of Employer Supervisor's Name

May we contact?

Salary

Position

Reason for leaving

Employment History 3

Date Month and Year

From

Name and Address of Employer Supervisor's Name

May we contact?

Salary

Position

Reason for leaving

Acknowledgements

I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for rejection or dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, with or without cause, and with or without any prior notice.

I hereby agree that, as a condition of employment by EPIC HOME HEALTH. will promptly inform the Agency in writing of any criminal convictions, in any jurisdiction (including all pleas of guilty), other than minor traffic offenses, of which I am convicted after today.

As an employee of EPIC Home HEALTH Care LLC. I have been informed that when clients are hospitalized, I cannot turn in timecards for those days even if I am at the hospital with the client. When clients are hospitalized, payment is made to the hospital for their care and the home care provider cannot bill for any services provided by PCAs. I also understand that if my client is on vacation or out of town and as a PCA I am not with the client, I cannot claim these hours. If timecards are turned in for these hours, this is fraudulent claims for payment. In both situations listed above, documenting that services were provided in the home is against agency policy, against the PCA Program and is considered falsifying records. Violation of these regulations is grounds for termination. I acknowledge that I have been informed of these policies and I understand that I may not claim these hours as hours worked. I am to notify the office when my client is not available to receive services at home.

Upload Fully Filled Employee Application Form*

Signature*

Signed Date*

Our Services

Download and fill the form below and attach it in the last step for you to qualify.

Personal Information

Employment Desired

Professional Licenses, Certification, and Registrations

References

Reference Details 1

Reference Details 2

Reference Details 3

Education

Highschool

College 1 Details

College 2 Details

Additional Training

Employment History

Employment History 1

Employment History 2

Employment History 3

Acknowledgements

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