Employment Application Note: Please complete each section and print legibly except where signatures are required Better Living Homes and Services is an equal opportunity employer and affords equal opportunity to all applicants without regard to race, color, religion, gender, national origin, age, disability, veteran status, marital or family status, genetic information or any other status protected under local, state or federal law.Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Social Security # Date of Birth MM slash DD slash YYYY HomeCellWorkDrivers License StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDrivers License Number NON-Drivers License StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificNON-Drivers License Number Are you at least 18 years of age or older? Yes ❑ No n Are able to rneet the physical and mental demands required to perform specific tasks for the client? yes no Do you agree to maintain confidentiality? Are you emotionally mature and dependable? Are you able to handle emergency situations? yes no Have you lived in Missouri for the past 5 years? Yes No If No, please list the state(s) you have lived in: Do you smoke? Yes No How did you learn of this postion? Is there any reason why you would not be able to perform the job duties? Yes No If Yes, please explain below: Better Living Homes and ServicesIf you are hired for a postition, background screenings via the Family Care Saftey Registry and Employee Disqualification List must be conducted prior to your first day of employment. PLEASE read the following questions, provide true and accurate information.HAVE YOU HAD ANY OF THE FOLLOWING IN MISSOURI OR IN ANY OTHER STATE: criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo contendere? Yes No If YES, list ALL criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo contendere AND the state in which this occurred. Do not list minor traffic offenses such as speeding tickets and parking tickets. If this dose not apply please use N/AList the offense and date for each crime: Do you give Better Living Homes and Services consent to conduct a pre-employment criminal record check? Yes No If No, please explain: Do you authorize Better Living Homes and Services to conduct a closed record check pursuant to Section 610.120, RSMo? Yes No If No, please explain: Have you ever used an alias? Yes No Better Living Homes and ServicesAre you registered with the Family Care Saftey Registry? Yes No If applicable, have you applied for a Good Cause Waiver? Yes No If YES, When? Do you have a skilled license? Yes No If YES, what type? (provide a copy) Do you have transportation? Yes No Have you ever worked with persons with physical and/or developmental disabilities? Yes No If yes, Please explain:Preferences and AvailabilityDo you prefer working with males, females or either? (question is for CNAs or PCAs) What days and hours are you available? Sun Mon Tue Wed Thurs Fri Sat Select AllPlease check the following duties that you are willing and able to perform on a daily basis Dressing Feeding Errands Laundry Transfers Shopping Bathing/Showering Toileting Routine Homework Cleaning Meal Preparation Correspondence Select AllEmployment History:Company Name: Phone: Supervisor: Position: Dates Employed: May we contact this employer? Yes No DutiesBetter Living Homes and ServicesReason for leaving:Are you eligible for re-hire? Yes No Company Name: Phone: Supervisor: Position: Dates Employed: May we contact this employer? Yes No Duties:Reason for leaving:Are you eligible for re-hire? Yes No Name/Title: Phone Address: E-mail: Name/Title: Phone: Address: E-mail: Name/Title: Phone: Address: E-mail: I certify that all of the information provided by me on this application and accompanying documents is true and complete. I understand that false representation or omission of any fact will be cause for denail of employment or termination of employment. I understand that if offered a position with Better Living Home and Services, I may be required to submit to a pre-employment drug screening.Signature of Applicant: Date: For Office Use ONLY:Employee Start Date: Rate of Pay $
