Illinois TPC Advantage Application

Employment Application

***Applications must be completed in their entirety. Incomplete applications will not be considered.***

We are an Equal Opportunity Employer
We participate in E-Verify

Name(Required)

First Middle Initial Last

Social Security #(Required)

Address(Required)

Number & Street City State ZIP / Postal Code

Home Phone Number(Required)

Work Phone Number

Other Phone Number

Date of Application(Required)

Position Desired(Required)

My Salary Expectations are:

Date available for work:(Required)

How did you hear about us? Or referred by:(Required)

Do you have any relatives/acquaintances employed by this company or affiliates?(Required)

Yes

No

If yes, list their name(s):

If employed, will you be able to submit verification, including a photo ID, of your legal right to work in the US?(Required)

Yes

No

Have you previously been employed by this company or its affiliates?(Required)

Yes

No

If yes, please provide:

Department

Position(s)

Dates:

Have you ever worked under any other name (alias)?(Required)

Yes

No

If yes, please provide the name(s)::

We do conduct background checks in accordance with federal, state, Medicaid requirements for health workers.

Work Preferences

I prefer(Required)

Full-Time

Part-Time

Work Hours Preferred(Required)

I can work:(Required)

Any Shift

Any Day

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

References

Reference 1(Required)

Name

Telephone

Number of Years Known

Reference 2(Required)

Name

Telephone

Number of Years Known

Reference 3(Required)

Name

Telephone

Number of Years Known

Skills and Qualifications(Required)

Summarize any training, skills, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Education and Language

High School Education(Required)

Name and Location

Years Completed (1, 2, 3, 4)

Did you graduate? (Yes or No)

Course of Study

College Education

Name and Location

Years Completed (1, 2, 3, 4, 5, 6)

Did you graduate? (Yes or No)

Course of Study

Other Education

Name and Location

Years Completed (1, 2, 3, 4)

Did you graduate? (Yes or No)

Course of Study

Are you a Registered Nurse?(Required)

Yes

No

Language Skills: If you SPEAK a foreign language(s), please indicate in the box below.

Language Spoken

Ability (Good or Fluently)

Language Skills: If you READ a foreign language(s), please indicate in the box below.

Language Read

Ability (Good or Fluently)

Language Skills: If you WRITE a foreign language(s), please indicate in the box below.

Language Written

Ability (Good or Fluently)

Employment History

A resume does not substitute for an employment application.
Provide the following information of your past and current employers or volunteer activities, starting with the most recent.
Explain any gaps in employment in the comments section below. (Include 5-years employment history.)

Employer 1(Required)

Employer 1 Start Date(Required)

Employer 1 End Date(Required)

Job Title(Required)

Employer 1 Phone(Required)

Address(Required)

Employer 1 Immediate Supervisor and Title(Required)

Hourly Rate/Salary Start(Required)

Hourly Rate/Salary End(Required)

May we contact this employer for references?(Required)

Yes

No

Type of work performed and job responsibilities(Required)

Employer 2

Employer 2 Start Date

Employer 2 End Date

Job Title

Employer 2 Phone

Address

Employer 2 Immediate Supervisor and Title

Hourly Rate/Salary Start

Hourly Rate/Salary End

May we contact this employer for references?

Yes

No

Type of work performed and job responsibilities

Employer 3

Employer 3 Start Date

Employer 3 End Date

Job Title

Employer 3 Phone

Address

Employer 3 Immediate Supervisor and Title

Hourly Rate/Salary Start

Hourly Rate/Salary End

May we contact this employer for references?

Yes

No

Type of work performed and job responsibilities

Comments - Include explanation for any gaps in employment.

Applicant Statement

Please read the following statements carefully before signing this application. Only those applications that are signed, dated and completed in full are considered valid.

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application, or immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. TPC Advantage, LLC is an Equal Opportunity Employer and a Drug Free Workplace.

I understand that this application remains current for only 30 days. At the conclusion of that, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurance to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president. I understand that I may be required to pass a drug test prior and/or during my employment.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I have read and understand the foregoing statements and accept the same as conditions of my employment.

Signature of Applicant(Required)

Date(Required)

Reference Request Release

Full Name: (First MI Last names)(Required)

Other names used during past employment:(Required)

Last four numbers of your Social Security Number:(Required)

I hereby authorize my current and/or past employers to release any and all references and records related to my current or past employment and work history to Advantage Home Care. I release you and your company from any and all liability for providing information regarding my employment and work history. I also authorize for Advantage Home Care to contact any personal references that I have provided to them and understand that my social security number may be provided in order to properly identify me.

Applicant Signature(Required)

Date(Required)

Background Check Policy

The Company, Advantage Home Care (includes Advantage In-Home Services, LLC , Advantage Consumer Directed Services, LLC and TPC Advantage, LLC) will obtain background checks as a consideration of employment that may include, but not limited to: employment and education verifications, social security verification, criminal history, civil history, consumer reports that include nationwide background checks, sex offender registry, highway patrol records, Department of Motor Vehicle (DMV) records, finger prints, Division of Homeland Security, public records of any kind, personal interviews and other screenings. As required by regulation, Advantage Home Care requires applicants to be registered with various state registrars prior to an employment offer being made. As allowed by law, applicants and employees are required to disclose all aliases, social security numbers and criminal convictions, findings of guilt, pleas of guilt and pleas of nolo contendere except in minor traffic violations. Applicants applying to work in the state of Illinois are not obligated to disclose sealed or expunged records of conviction or arrest, nor if they exist. All employees are required to complete an I-9 at hire and provide proof of identity. Advantage Home Care participates in E-Verify through the Division of Homeland Security. Employment is contingent upon the results of thorough background checks pursuant to federal and state regulations and Company policy. Persons found guilty of a prohibited offense as defined by regulation, regardless of adjudication or a plea of nolo contender, are not eligible for employment. Other offenses and findings may require a formal waiver to be obtained before employment will be considered as defined by regulation or make a person ineligible for employment per company policy and/or company discretion. Background checks are conducted prior to hire and throughout employment.

Authorization

I have read and understand the Background Check Policy and agree to the terms of the policy. I authorize the Company, Advantage Home Care (includes Advantage In-Home Services, LLC, Advantage Consumer Directed Services, LLC and TPC Advantage, LLC) to obtain a thorough background check on me and understand that employment is contingent on the results of all screenings. If employed by Advantage Home Care, I acknowledge and authorize continued background screenings to be conducted throughout employment.

Print Name(Required)

Signature(Required)

Date(Required)

Do you reside in the same state you are applying to work in?(Required)

Yes

No

Have you resided in your current state for the past 5 consecutive years?(Required)

Yes

No

DISCLOSURE

In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, [TPC Advantage, LLC] (“the Company”) may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc.

For explanation purposes:

* a “consumer report” is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and

* an “investigative consumer report” is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (“FCRA”).

Under the FCRA, before TPC Advantage, LLC can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

AUTHORIZATION

I have read and understand the foregoing Disclosure, and authorize TPC Advantage, LLC to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize TPC Advantage, LLC to obtain any such reports and to share the information received with any person involved in the employment decision about me.

I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.

Applicant Signature(Required)

Date(Required)

Personal Data

Name(Required)

Last Name First Name Middle Name

Current Address (include street, city, state, zip code)(Required)

Dates Lived Here(Required)

Addresses for the Past Seven Years: (include street, city, state, zip code)

Previous Address 1:

Dates of Residence:

Previous Address 2:

Dates of Residence:

Previous Address 3:

Dates of Residence:

Date of Birth(Required)

Other Names Used (including maiden name)

Years Used

Social Security Number(Required)

Email address (may be used for official correspondence)(Required)

I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.

I certify that all of the elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

Printed Name(Required)

Signature(Required)

Date(Required)

Applicant Notice

All individuals completing an application for the Health Care Worker Registry are required to have a fingerprint-based background check submitted to the Illinois State Police as a Fee Application inquiry requested by the Illinois Department of Public Health. Your fingerprints must be collected by one of the four livescan vendors contracted by the Department. Any other type of background check will not be accepted. Once you have completed the enclosed application and returned it to the Health Care Worker Registry, a Livescan Request Form will be sent to you that will allow you to have your fingerprints collected for the correct type of background check. You or your employer are required to pay for the background check.

Please complete the application and send it to:

Illinois Department of Public Health

Health Care Worker Registry

525 W. Jefferson St. Fourth Floor

Springfield, IL 62761

APPLICANT SHADOWING AGREEMENT

TPC Advantage, LLC and applicant have mutually agreed to job shadowing in a specified Advantage office location.

* The applicant is only able to shadow after the appropriate background checks have been completed and the applicant has been cleared by management for shadowing.

* The applicant is not expected to perform any work during their time shadowing.

* Time spent shadowing is not paid.

* There is no guarantee that a job offer will be extended.

*Confidentiality: Healthcare providers are legally required by the Health Insurance Portability and Accountability Act (HIPAA) and state law to protect the privacy and security of health care information of all patients and employees.

- Your visit to our facility may include access to patient and employee information. Under no circumstances may this information be disclosed with anyone. State and Federal law prohibits you from making any disclosure of patient information. Legal action will be taken if it discovered that you disclose PHI.

*During the time spent shadowing, the applicant will be potentially exposed to agency policies, procedures, billing and payroll information, accounting data, confidential information relating to the performance and activities of business functions, etc. It is expected that such confidential information be preserved consistent with the law and the applicant agrees as follows:

- Both during the term of this Agreement and thereafter, the applicant agrees:

+ Under no circumstances will the applicant divulge ANY confidential information (especially client and employee PHI) they saw or heard during and after their time shadowing with the agency.

+ The applicant shall return all documents in his/her possession at the end of the shadowing session back to the office. (Except for application paperwork that pertains to future employment).

*Release

- I understand and agree that Advantage Home Care, its’ employees, or owners may not be held liable in any way for any injury, illness or other damages that may result during the job shadowing program. I understand that I am not an employee of the homecare agency at this time and am not entitled to compensation and benefits for my participation in the job shadowing program.

The undersigned understands that any violation of this Agreement is grounds for no future employment offer being made and potential legal action against them.

Applicant Full Name(Required)

Shadowing Office Location

Date of Shadowing

Applicant Signature(Required)

Date(Required)

TPC Signature (not for applicant)

Please upload a valid Illinois drivers license or state ID

Max. file size: 450 MB.

Please upload your social security card

Max. file size: 450 MB.