New Hire Forms

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Applicant - New Hire

Applicant Full Name*

First Name Middle Name Last Name

Authorization to Release Information

AUTHORIZATION & CONSENT FOR RELEASE OF INFORMATION

In consideration for employment or promotion DISCOVERING KINDNSS IN HOME SERVICES LLC, Employers Reference Source may make inquires, including but not limited to, your consumer credit history, education, professional licensing, criminal history, driving record, your personal character, abilities, work habits, mode of living, residency, immigration status, general reputation, performance, experience and other qualities pertinent to your qualifications for employment, including reasons for termination from you past employment.
In compliance with the American with Disabilities Act, only after a contingent offer of employment is offered, will your worker's compensation history be investigated for the purpose of making certain that you are not hired for a position or assigned to a job function that could aggravate a previous injury.
In compliance with the Fair Credit Reporting Act, you are entitled to be informed if an offer of employment is withheld because of information obtained from Employers Reference Source and, in that event, we will provide a copy of the report we receive and the FTC notice. “A Summary of Your Rights Under the Fair Credit Reporting Act.”
Please complete and sign the form below, authorizing, without reservation, any party, including but not limited to, employers, law enforcement agencies, state agencies, institutions and private information bureaus or repositories, contacted by Employers Reference Source to furnish any or all of the above listed information. Your authorization releases Employers Reference Source from any and all liability for damages arising from the investigation and disclosure of the requested information. Further, it releases and discharges all liability from all companies, agencies, officials, officers, employees and other persons, who, in good faith, provide to Employers Reference Source the above-mentioned information as requested, in order to successfully complete a background investigation.

Applicant Name:*

First Name Middle Name Last Name

Have you used any other name?*

Yes

If YES, list other name(s) used:

Social Security Number:*

Date of Birth:*

Driver's License Number:

State of Issue:

Have you lived in Connecticut less than 3 year?

Yes

If YES, list address and state(s):

Please provide the date of nay motor vehicle convictions:

Have you been convicted of a crime involving violence or dishonesty in a state court or federal court in any state or was subject to any decision imposing disciplinary action by a licensing agency in ay state, the District of Columbia, a United States possession or territory or foreign jurisdiction?*

Yes

“I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.”
R.C.S.A. Section 20-670-2(b) (regulations); C.G.S. Section 20-675(a)(4) The agency shall maintain the above form and comprehensive background check for each agency employee during he time of employment and for a period of three years from the date of the end of the employment relationship.
C.G.S. Section 20-681 Covenants not to compete, homemaker, companion, home health services. Prohibition established. For purposes of this section “covenant not to complete” means any contract or agreement that restricts the right of any individual to provide homemaker, companion, or home health services (1) in any geographic area of the state of any period of time, or (2) to a specific individual. Any covenant not to compete is against public policy and shall be void and unenforceable.
*Date of birth requested only for purposes of identification in obtaining accurate retrieval of records and it will not be used for discriminatory purposes.

Signature*

Date*

HCA.0001488

Applicant - New Hire

Application

EMPLOYER APPLICATION FOR EMPLOYMENT

GENERAL INFORMATION:

EDUCATION & SKILLS:

EMPLOYMENT HISTORY:

REFERENCES: (list ONLY professional or work references):

APPLICATION CONSENT:

Please Read Carefully Before Signing

Authorization to Release Information

AUTHORIZATION & CONSENT FOR RELEASE OF INFORMATION

Release of Information to Employers

EEO

WHAT IS YOUR RACE/ETHNICITY?

New Hire Forms

Applicant - New Hire

Application

EMPLOYER APPLICATION FOR EMPLOYMENT

GENERAL INFORMATION:

EDUCATION & SKILLS:

EMPLOYMENT HISTORY:

REFERENCES: (list ONLY professional or work references):

APPLICATION CONSENT:

Please Read Carefully Before Signing

Authorization to Release Information

AUTHORIZATION & CONSENT FOR RELEASE OF INFORMATION

Release of Information to Employers

EEO

WHAT IS YOUR RACE/ETHNICITY?

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