SECTION 1 GENERAL INFORMATION :

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PLEASE TYPE YOUR LEGAL NAME

First Name: Middle Initial: Last Name:

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Address: 

Telephone:  Cell Phone:  Email: 

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Can you: speak English write English read English

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Are you fluent in any languages other than English? Yes No Specify?

Speak Read Write

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Position For Applying: Direct Care Worker

Have you ever applied for employment with RHMT? Yes No Whene/Were?

Employment desired: Full time Part time Relief (On Call) Daytime Evening Overnight Weekend

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Times you are available:

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
From
To

Locations/Areas desired:

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If you were referred to us from a current RHMT employee, please give us their name:

SECTION 2:

Education Requirements	Do you have a high school diploma or G.E.D.?	Yes No
Letters of Reference	Can you supply three letters of reference/List of professional References	Yes No
Employment Eligibility	Are you eligible to work in the United States?	Yes No
Age	Are you at least 18 years old?	Yes No
Physical Requirements	Are you able to meet the physical requirements as described on the job description with or without reasonable accommodation?	Yes No
Driving Eligibility	Do you have a valid State Driver’s License for the state in which you are applying, and	Yes No
	Are you at least 21 years old?	Yes No
	Do you have a clean driving record?	Yes No
Fingerprint Clearance (Arizona only)	Do you possess a current, valid Fingerprint Clearance card?	Yes No

SECTION 3:

Conviction Record	Have you ever been convicted of or are you awaiting trial for a felony or misdemeanor?	Yes No
Arizona Central Registry	Do you have a substantiated finding with Child Protective Services (CPS) or Adult Protective Services (APS)?	Yes No
List of Excluded Individual and Entities	Are you currently on the Office of Inspector General’s List of Excluded Individuals and Entities?	Yes No

SECTION 4 EDUCATIONAL BACKGROUND Please PRINT using BLACK ink only

Name of Institution	Number of Years Completed	Major	Degree	Graduated
High School
College
Other
Other Skills/Certifications:

SECTION 5 REFERENCES Please provide four (4) references, preferably persons who are familiar with your work/training. Certain positions require at least two (2) business related reference. References cannot not be a family member, a Fiancé, a significant other or a boyfriend/girlfriend.

Name	Address	Phone Number	Relation Ship	Years Known (Yrs/Mo)

SECTION 6 EMPLOYMENT HISTORY Please list 3 employers for the past ten years, beginning with the most recent. Please see the receptionist if you need an additional sheet. This information must be completed even if you are submitting a resume

1)
Employer: Type Of Business: Telephone:

Address: Last Position Held:

Dates Employed: / to / Supervisor’s Name:

May we contact: Yes No

Job Functions:

Reason for Leaving:

Starting Salary: Ending Salary:
2)

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Employer: Type Of Business: Telephone:

Address: Last Position Held:

Dates Employed: / to / Supervisor’s Name:

May we contact: Yes No

Job Functions:

Reason for Leaving:

Starting Salary: Ending Salary:
3)

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Employer: Type Of Business: Telephone:

Address: Last Position Held:

Dates Employed: / to / Supervisor’s Name:

May we contact: Yes No

Job Functions:

Reason for Leaving:

Starting Salary: Ending Salary:

This application and all attached documents become official records of RHMT and will not be returned. This application for employment expires after 30 days. I understand that if I have not heard from RHMT in 30 days and still wish to be considered for the position I will need to complete a new application packet. I understand that RHMT is an Employment-At-Will Employer, which means that either RHMT or I can terminate the employment relationship at any time for any lawful reason. I understand that this Employment-At- Will relationship can only be altered by a written employment contract specific to all terms and conditions of employment which is signed by both myself and the RHMT. I hereby certify that the information contained in this application and related documents are true, correct and complete to the best of my knowledge and belief. I am aware that should an investigation at any time disclose any misrepresentation or falsification, my application will be rejected, or if discovered subsequent to hiring, will be grounds for termination. I authorize RHMT to make all necessary and appropriate investigations to verify the information contained herein.

I AGREE

CONFIDENTIAL Background
Check Authorization

Issue Date: / / Driver’s License#: State Issued: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Last Name: First Name: MI:

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Maiden and/or Other Last Names Used:

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Current Address: City and County:

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State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:

Date of Birth: / / SSN#:

The information contained in this application is correct to the best of my knowledge. I hereby authorize Reliable Health & MedTrans, LLC and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to Reliable Health & MedTrans, LLC or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. I hereby release Reliable Health & MedTrans, LLC, the Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

I AGREE

RHMT’S Voluntary Applicant Data Record

his information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or is necessitated by another federal law or regulation. Please be advised that this information is not a part of your official application for employment. It is confidential information for statistical data gathering purpose only and will not be made available to those making the hiring decision. Reliable Health & MedTrans, LLC does not unlawfully discriminate in the employment process on any basis prohibited by local, state of federal law. Your cooperation in providing this information is appreciated.

Full Name: Address: Position Applied For:

Date: / /

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Please select one of the following: American Indian/Alaskan Native Native Hawaiian or Other Pacific Islander Hispanic or Latino Black or African American White (not of Hispanic origin) Two or more races Other	Please select one of the following: Under 30 31 - 40 41 – 50 51 – 59 60 +
Please select one of the following: Disabled Veteran Vietnam Era Veteran Individual with Disability None	Please select one of the following: Male Female
How did you learn about employment opportunities with RHMT?: Referral DES Job Service Internet/other Websites Referral from current/past employee) Referral from a friend (not current/past employee) Walk-in Other