Personal information
Present address
Permanent address
Employment desired
Such conviction may be relevant if job related, but does not bar you from employment.
Education
Subjects Studied
Academic
Trades of Business
EMPLOYMENT HISTORY
REFERENCES
Give the names of three persons not related to you to whom you have known at least 1 year
In case of Emergency notify
INITIAL Conditions of Employment – please read carefully
Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary. I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information. The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law. Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation, and failing settlement in mediation, to binding arbitration. Unless otherwise agreed, a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company. Panel of mediators will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce. This application is valid for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.
Clear
VA SWORN DISCLOSURE STATEMENT
APPLICANTS FOR HOME CARE ORGANIZATION
To The Job Applicant: Section 32.1-162.9:1 of the Code of Virginia requires that any applicant for employment with a licensed home care organization provide the Commissioner's representative with a sworn statement disclosing (1) whether the applicant has a criminal conviction or is the subject of any pending criminal charges within or outside The Commonwealth of Virginia, and (2) whether the applicant has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth of Virginia. Any person making a materially false statement on this form shall be guilty of a Class 1 misdemeanor. Further dissemination of the information provided on this form is prohibited other than to the Commissioner's representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.
I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification.
BACKGROUND DISCLOSURE
SWORN STATEMENT
By execution of this document, I acknowledge that I have been informed by the Agency that a criminal history check will be performed on my name. I have informed that Agency of all names (for example, maiden name, aliases) that I have used in the past. I understand that I have been employed on a provisional basis and that my employment is temporary pending the results of the criminal history check. I also understand that the Agency will not hire me if I have been convicted of the offenses enumerated below. I also understand that the Agency will search all available registries and other sources to determine whether any acts of abuse, neglect or exploitation have occurred and whether my name is designated on any registry. If my name is designated on either registry I understand the Agency will deny me employment.
DISQUALIFYING OFFENSES
Generally, criminal convictions for offenses involving abuse or neglect disqualify an applicant. Murder and manslaughter Malicious wounding by a mob Kidnapping and abduction with intent to deprive of personal liberty or to withhold or with intent to extort money, or with intent to defile, and abduction of a child under 16 for concubine or prostitution Assaults and bodily wounding, including: • shooting, stabbing, or wounding with the intent to maim or kill • malicious or unlawful wounding of a law enforcement officer or firefighter • aggravated malicious wounding • reckless endangerment by throwing objects from places higher than one story • maiming of another resulting from driving while intoxicated • malicious bodily injury by use of a caustic agent, or use of any explosive, or fire • possession of infectious biological substances • shooting, stabbing, cutting, or wounding while committing, or attempting to commit, a felony • use, or display, of a firearm in the commission of a felony • poisoning or attempted poisoning • adulteration of food, drink, cosmetics, and drugs • bodily injuries by prisoners, parolees, or probationers • pointing a laser at a law enforcement officer • hazing • reckless handling of firearms • allowing children access to loaded firearms • assault and battery or simple assault • Assault and battery against a member of the family or household. Robbery Carjacking Threats of death or bodily injury Felony stalking Sexual assault, including: rape carnal knowledge of a child 13-15 years of age carnal knowledge of a minor in custody carnal knowledge of an inmate, parolee, probationer, or pre-trial or post-trial offender forcible sodomy inanimate object sexual penetration marital sexual assault aggravated sexual battery infected sexual battery sexual battery attempted rape, forcible sodomy, object sexual penetration, sexual battery, or aggravated sexual battery Arson, including: setting fire to a dwelling, occupied hotel, hospital, mental health facility, railroad car, boat, vessel or river craft, jail, church, or other house in which persons live setting fire to a meetinghouse maliciously or with intent to defraud an insurance company or other person, setting fire to any other building, or structure, or to personal property bomb or arson threats against buildings or other structures or against means of transportation manufacturing, possessing, or using firebombs or other explosive material maliciously or intentionally setting fire to woods, fences, grass, etc. setting off smoke bombs in public buildings carelessly damaging property by fire setting woods, brush, grass, etc. on fire and intentionally allowing fire to escape to lands not his own, whereby property of another is damaged or jeopardized burning building while in building with intent to commit felony false threat to bomb or damage building or means of transportation Drive by shooting Use of a machine gun in a crime of violence Aggressive use of a machine gun Use of a sawed-off shotgun in a crime of violence Pandering, including: • pimping • enticing persons to become engaged in prostitution, and • as legal guardian, consenting to minor's being detained for prostitution or unlawful sexual intercourse, compelling one to be married against his or her will. Crimes against nature involving children Incest Taking indecent liberties with children including: • fondling • indecent exposure • propositioning a child to engage in such behavior or in sexual intercourse • enticing minors to be subject of sexually explicit visual material Abuse and neglect of children Failure to secure medical attention for an injured child Obscenity offenses including: • production, publication, sale, or possession with the intent to distribute sexually explicit items involving children • employing, assisting, or permitting a minor to engage in obscenity Possession of child pornography Electronic facilitation of pornography Abuse and neglect of incapacitated adults Delivery of drugs to prisoners Escape from jail Felonies by prisoners An equivalent offense in another state.
I, (print name): ,do hereby confirm that I have not been convicted of any crime listed above. I further confirm that there are no charges currently pending against me with respect to the above listed offenses *.
*Any person making a materially false statement on this form shall be guilty of a Class 1 misdemeanor and, upon discovery, will be disqualified for employment with this Agency.