Employment History

Position(s) Applied For

Date of Application

Recuiter*

Expected Salary/Hourly Rate

How did you learn about us?
Advertisement Friend	Walk-In Employment Agency	Relative Other
Referral By:

Last Name	First Name	Middle Name

Address	Number	Street	City	State	Zip Code

Previous Address

How Long?

Telephone Number(s)

Home:

Cell:

Social Security Number

Do you have a valid Driver's License?

Yes

Chauffeur's License?

Yes

Have you ever filed an application with us before?

Yes

If yes, give date

Have you ever been employed with us before?

Yes

If yes, give date

Are any of your relatives currently employed by Omni Home Care?

Yes

If yes, please explain

Are you currently employed?

Yes

May we contact your present employer?

Yes

On what date would you be available for work?

Are available to work?

Full Time

Part Time

Per Diem

Are you currently on "layoff" status and subject to recall?

Yes

Can you travel if a job required it?

Yes

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?

Yes

Proof of citizenship or immigration status will be required upon employment.

Are you capable of performing in a reasonable manner the activities involved en the job or occupation for which you have applied?

Yes

Have you ever been convicted of a felony, entered into a deferred prosecution agreement, or had adjudication withheld?

Yes

Conviction will not necessarily disqualify an applicant from employment.

If yes, please explain

Have you ever been accused by an employer, supervisor, school authority, or a law enforcement agency of wrongdoing or misconduct?

Yes

If yes, please summarize the allegations and describe how the allegations were resolved:

Have you ever been excluded, suspended, or debarred from participating in government programs such as Medicare or Medicaid?

Yes

If yes, explain:

Employment Experience

Start with your present or last job (include any job-related military service assignments and volunteer activities).

Employer:

Address:

Telephone Number:

Job Title:	Supervisor:

Reason for leaving:

Dates Employed

From:

To:

Hourly Rate/Salary

Starting: Final:

Work Performed

Employer:

Address:

Telephone Number:

Job Title:	Supervisor:

Reason for leaving:

Dates Employed

From:

To:

Hourly Rate/Salary

Starting: Final:

Work Performed

Employer:

Address:

Telephone Number:

Job Title:	Supervisor:

Reason for leaving:

Dates Employed

From:

To:

Hourly Rate/Salary

Starting: Final:

Work Performed

Professional References

Name:

Phone:

Address:

Years Known:

Name:

Phone:

Address:

Years Known:

Name:

Phone:

Address:

Years Known:

Education


	Name and Address of School	Course of Study	Years Completed	Diploma Degree
Elementary School
High School
Undergraduate College
Graduate Professional
Other (specify)

Person to Contact in Case of Emergency

Name:

Home Phone:

Work Phone:

Address:

Relation:

Other Qualifications


Summarize special job-related skills and qualifications acquired, foreign language or other experience.

Drug free workplace testing consent

"I understand that OMNI Home Health Services, LLC, and all Subsidiaries and Affiliates("OMNI") has a drug-free workplace policy and submission to blood/urine testing, if requested, is a condition of employment and continued employment. I hereby agree to submit to such testing or examination, at OMNI's expense, at any time during the hiring process and my employment. I understand that my refusal to do so or certain positive drug screening results may result in OMNI's refusal to hire me or my immediate termination." Refer to employee handbook for details.

Criminal and motor vehicle background screening consent

"I understand that OMNI may perform background screenings that include checks of civil, criminal, financial history, government sanction, and/or motor vehicle records in connection with my application for employment. I also understand that OMNI may perform such background checks on a periodic basis as needed and that any adverse information found as a result of the background checks may result in immediate disqualification of my candidacy, or termination of my employment, depending on the sensitivity of the position and extent of the findings. I hereby authorize without reservation any public or private agency, service bureau, insurance agencies, reference companies or other sources public or private, contracted by OMNI or any of its agents to furnish the information requested. I understand that in accordance with federal law I will be entitled to receive an "adverse action notice" in the event that employment is denied or I am terminated as a result of information obtained by OMNI or its affiliates from any of these sources. If so, I will be notified, given the name and address of the reporting entity and provided a copy of my rights under the Fair Credit Report Act."

References Investigation Consent

“I give OMNI the right to investigate all references and to secure additional information about me if job related. I hereby release from liability OMNI and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.”

Non-Disclosure of proprietary information of previous employer

By signing below, I acknowledge that in connection with my employment with OMNI or any of its affiliates, I have not been asked to, nor will I use, disclose, or implement any proprietary information or intellectual property belonging to any of my prior employers.

Non-Compete agreement(s) with previous employer(s)

By signing below, I acknowledge that I am not currently under any non-compete agreements with a previous employer that would hinder my employment with OMNI.

Non-Solicitation agreement as a condition for employment

“I understand that if hired into a full time position, I will be required to sign a non-solicitation agreement as a condition of hire.”
“I certify that answers given herein are true and complete to the best of my knowledge. It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from OMNI’s service if I have been employed. Further, I understand that just as I am free to resign at any time, OMNI reserves the right to terminate my employment at any time, with or without cause and without prior notice. I
understand that no representative of OMNI has the authority to make any assurances to the contrary.”

Notice regarding OMNI hotline

The OMNI Toll Free Hotline (866-364-6664) exists to allow employees, patients and anyone doing business with OMNI Home Care to report any suspected violation of law, OMNI’s Compliance Plan, and other misconduct or grievances. You may identify yourself or report anonymously. OMNI will make every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who uses the OMNI Hotline. There will be no retribution or disciplinary action towards anyone who reports a concern in good faith. This hotline is manned 24-hours a day by a third party vendor which will assign you a case number. When calling we will require the location/state of the complaint being reported in order to properly investigate the
matter. Reports are logged and forwarded daily to the Director of Compliance and the Director of Human Resources for investigation and resolution. All reports become permanent records of OMNI.

Notice of voluntary resignation policy

It is our sincere hope that our employee’s tenure with OMNI is long lasting. However we understand that circumstances change and employees may need to voluntarily resign from their position with OMNI. If this should occur, it is our policy that employees provide a month of advance notice. The notice period will assist OMNI in allowing time to find a replacement, as well as assist the employee in the exit process.
In some circumstances, it may be necessary for OMNI to adjust the employee’s last day of employment to a date sooner than the employee’s original end date. In these situations, OMNI will not pay the employee for the full notice period.
Please sign below to acknowledge understanding of this policy.

I accept