107 Windel Drive Suite 105 Raleigh, NC 27609 Phone:919-788-1400
 
  Page #1

 

Applicant Personal Information
 
Application Date:      
Email Address:     Social Security Number:       
First Name:     Middle Initial:     Last Name: 
Maiden Name (if applicable): 
Street Address:    City: 
State:      Zip Code:      County: 
Phone Number:          Cell Phone Number:  
Preferred method of electronic communication   
Date of Birth
Country of Birth
Gender
Ethnicity
Height   ft                          inches
Weight
Hair
 
Applicant or Authorized Representative Review and Verification

(All applicants looking for employment must complete and sign this Section. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
                  List A                                                OR                        List B                                   AND                                  List C
     Identity and Employment Authorization                                                                                       Identity                                                                                                       Employment Authorization

Document Title
 
Document Title
                Acceptable IDs

Document Title
Document Number
  Document Number
Document Number
Expiration Date (if any)(mm/dd/yyyy)
  Expiration Date (if any)(mm/dd/yyyy)
Expiration Date (if any)(mm/dd/yyyy)
Attach Front of ID
  Attach Front of ID
Attach Front of ID
Attach Back of ID
  Attach Back of ID
Attach Back of ID
 
Certification: I attest, under penalty of perjury, that the above-listed documents are genuine and relate to the applicant.
 
Signature of Applicant

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Today's Date (mm/dd/yyyy)    
 
 
 
Emergency Contact
 
First Name          Last Name  
Phone Number:          Email: 
Relationship               Street Address
City         State      Zip
 
  Page #2

 

Position Related Information
 
Office where you are applying               Have you applied to this company before? 
Are you currently certified?    CNA   HHA  
 
 Type of Employment desired (check all that apply)
 
 Full Time       Overnights   
Did you have an appointment or are you a walk in?  How did you hear of us? 
if you have been referred by one of our employees, please complete below
REFERRED BY - NAME: REFERRED BY - NUMBER 
 
 
 Languages known
Primary Language : 
Other Languages Known :

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  Page #3

 

Education: Write “N/A” if no degree was obtained
Level of Education Name & School Address Years Attended Degree Obtained Subject Studied
High School
College
Trade School
Other
 
 Training and additional certifications:
 Please list any additional relevant education, training or skills:
 
 
  Page #4

 

 Conditions of Employment

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. (with the exception of a drug authorized by a physician/primary health care provider for the employee's use while on the job, and whose performance is not noticeable impaired will not be considered in violation of this policy. Employees are responsible for asking the prescriber about any side effects that may influence performance.)


 

I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without prior notice.




The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no questions 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




As a Home Care Agency, Broadway NC is required to obtain certain medical records from our applicant. Broadway NC offers applicants the chance to get all medicals done at a contracted facility for free, at the time of the visit. It is the applicant's responsibility to understand upon employment the balance paid for the visit by Broadway NC will be withdrawn slowly out of each payroll period until the balance is paid back to the agency in full. Once full payment is received, upon request, the applicant may have a copy of their records. If the balance is not paid or employment does not occur, records remain with Broadway NC and are not permitted to be distributed. I agree to have Broadway NC pay the balance for my visit. I also agree, once employed with them, to have the balance that was paid slowly taken from my payroll. If, for any reason, employment with the above agency does not take place, I understand the medical records can not be released to me.

Below is a list of procedures and the cost of each. If you prefer to have any of these procedures done at our facility you are agreeing to have the cost amount withdrawn slowly out of each payroll period until the balance is paid back to the agency in full.
 
  • Pre-employment physical - $65
  • QuantiFERON TB Blood Test - $85
  • Chest X-Ray - $75

 
Applicant Signature:    

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Signatures must be filled in properly or the application will be rejected, IE just drawing a line will not be considered a valid signature

Date Signed :  
 
  Page #5

 

Professional Home Care Employment Information

Company Name         Job Title Held    
Best Contact Person      Phone Number       Fax Number  
 
By signing below, you are providing your consent for us to contact the above named employers. All information is kept confidential.
 Date Signed:  
 Applicant Signature: 

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Signatures must be filled in properly or the application will be rejected, IE just drawing a line will not be considered a valid signature

 
 
  Page #6

 

Reference Information
 
1 First Name         Last Name
  Street AddressCity
  State                  Zipcode 
  Phone Number    Email Address  
   
  Number of Years Known
   
2 First Name   Last Name
  Street AddressCity
  State             Zipcode
  Phone Number    Email Address  
   
  Number of Years Known
   
 
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 Hepatitis Information Acknowledgement

Hepatitis B infection is a viral infection of the liver which may be transmitted from person to person by direct contact with blood/body fluids, secretions, or excretions of the infected person. This can be transmitted from individuals who are carriers of the disease to facility personnel. A carrier of Hepatitis B is defined as a person who may or may not have symptoms of the infection, and in whom the virus remains alive in the blood or other body fluids. Hepatitis B infections may result in chronic infection of the liver, cirrhosis, and less frequently, liver cancer
Consent 
If I accept the vaccination, I understand that I will be given the opportunity to participate in the series, which includes injections at 0, 30, and 180 day intervals. I will comply with the administration procedure and am aware of the adverse effects, contraindications, and complications that may occur due to the contraindications, and complications that may occur due to the Hepatitis B Vaccination
Declination

If I decline the vaccination, I either have received the vaccination prior, OR understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
 
Accept the Hepatitis B Vaccine inoculation
I have read and understand the information regarding Hepatitis B. My signature below indicates acknowledgment of this information and my decision to either accept or decline the Hepatitis B vaccination.

By signing below, you are DECLINING to participate in the HEP-B program.

Applicant Signature
 

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Signatures must be filled in properly or the application will be rejected, IE just drawing a line will not be considered a valid signature

Date Signed:
 

Agency Rep. Signature
 
 
Date Signed:
 
     
 
  Page #8

 

 Background Check Disclosure,
Authorization & Release


 
 CRIMINAL BACKGROUND CHECK DISCLOSURE STATEMENT

In connection with your employment application or your actual employment, Broadway NC or its affiliates (the “Company”) may obtain a “criminal background report” and/or an “investigate criminal background report” about you for employment purposes. The information contained in such criminal background reports may be used by the Company for employment purposes, such as hiring you. If you are hired by the Company, the information in a criminal background report may be used for other employment purposes, such as promotion, retention, and termination.

A “criminal background report” may contain the following types of information about you: criminal history including felony filings, misdemeanor filings, and motor vehicle records, ETC. An “investigative criminal background report” is broader and seeks information that bears on your character, general reputation, personal characteristics, or mode of living that is compiled through the use of personal interviews with references, employers, neighbors, friends, associates, ETC. in order to be used for employment purposed. You have a right to request disclosure of the nature and scope of the reports. If the Company obtains a criminal background report or an investigative criminal background report about you, and if the Company considers any information when making an employment decision that directly and adversely affects you, will be provided a copy of A Summary of Your Rights Under the Fair Credit Reporting Act in the addition to a copy of any report furnished by a consumer reporting agency during the background check process
 
AUTHORIZATION TO CONDUCT CRIMINAL BACKGROUND REPORTS

I authorize the Company to obtain criminal background reports and/or investigate criminal background reports for the pre-employment background investigation, and, if I am hired, at any time during my employment. I understand that these reports might include, but are not limited to, a search of my criminal background, reference checks, driving record checks, and verification of my identification and Social Security number. I agree that this Disclosure/Authorization, in original or copy form, is valid for all current and future criminal background reports. I understand that providing any false information or omitting any material information on my application materials or in the interview process will be sufficient grounds for rejection of the application, or termination of employment whenever discovered.
 
Driver License/Government-Issued ID State:    License/ID Number: 
The following is for identification purposes only to perform the background check
Other or Former Last Names:  
Professional License:   State:  Type:  Zip: 
Signature:
 

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Signatures must be filled in properly or the application will be rejected, IE just drawing a line will not be considered a valid signature

Date: