Staff Application Form - Heart and Home Staffing LLC

Name

First

Last

Date of Birth

Social Security Number (SSN):

Email

Phone Number

Home Address:

Position Applying For (Check one)

Preferred Start Date:

Employment History (Include the past three employers)

Employer 1 (Include: Name of Employer, Position Held, Employment Date, Leave Date, and Reason for Leaving)

Employer 2

Employer 2 (Include: Name of Employer, Position Held, Employment Date, Leave Date, and Reason for Leaving)

Employer 3

Employer 3 (Include: Name of Employer, Position Held, Employment Date, Leave Date, and Reason for Leaving)

Education & Certifications

Relevant Certifications (Check all that apply)

Background Screening Authorization

Yes
No

Have you ever been convicted of a felony or misdemeanor? (Tick yes or no above).

If Yes, explain below:

Emergency Contact Information

Name, Phone Number, and Relationship of emergency contact

Applicant's Signature & Agreement (Type Full Name)

I certify that the information provided is accurate to the best of my knowledge. I understand that false information may result in disqualification or termination.

Authorization for Background Screening (Insert Full Name)

I hereby authorize Heart and Home Staffing LLC to conduct a thorough background check as part of the employment screening process. This authorization allows the agency to obtain information regarding my: 1. Criminal History – Review of state and federal criminal records to ensure legal eligibility. 2. Sex Offender Registry– Verification against national and state databases. 3. Employment History– Confirmation of previous employment, job performance, and reliability. 4. Educational & Certification Verification – Validation of professional licenses, degrees, and healthcare-related certifications. 5. Professional References – Contacting former supervisors and colleagues to assess work ethic and qualifications. I understand that this background check is required for employment consideration and staffing placements within healthcare facilities. Heart and Home Sta,ing LLC – Employment Application Packet Page 5 5 Disclosure & Compliance Statement Pursuant to the Fair Credit Reporting Act (FCRA) and state regulations, I acknowledge the following: – Background screening is performed in compliance with Maryland COMAR 10.07.03.08 and relevant employment laws. – I have the right to request a copy of any background report obtained. – If adverse action is taken based on background check results, I will receive written notification and the opportunity to dispute any inaccurate information. Consent & Signature By signing above, I authorize Heart and Home Staffing LLC to proceed with my background screening. I affirm that the information provided is accurate to the best of my knowledge.

Birth Authorization Screening

Date Completed

Any additional information

Apply Today!

Heart and Home Staffing LLC Employment Application Form