APPLICATION FOR EMPLOYMENT
(Please Fill Out Completely)
Date of Application
Social Security Number _____/____/______
Print Full Name
Home Phone:
Mobile:
Email:
State
Zip Code
Address
City
Position Applied For
Documents required with this application (All)
1. Thoroughly completed employment application
Check if attached
( )
2.
Current Professional License (Signed), if any
( )
3.
Current CPR card/First Aid (Signed)
( )
4.
PPD/Chest X-Ray /Medical
( )
5.
Employment Eligibility Verification (Form I-9)
( )
6.
One personal reference form or letter (phone # included)
( )
7.
Driver’s License/ State Issue ID card (Signed)
( )
8.
Copy of Social Security Card (Bring original signed copy to interview)
( )
9.
One year of experience working in the field
( )
10. Background Check (a must)
( )
11. Any other information you have for employment
( )
If you do not have all the documents above, please tell us when it will be available:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
4920 Niagara Rd Ste 116, College Park MD 20740
Email: [email protected]
Phone: 301-486-4502 Fax: 301-486-4503
Website: www.michomecare.com
1
CJIS Background Check Process
1. You must bring a valid form of government identification. (Examples: driver's license,
Certificate of Naturalization, passport, Alien Registration Card, or Military Identification)
2. Fill out the attached form, print it and bring it to any fingerprinting center.
Livescan Pre-registration Application
3. Bring payment as indicated below. Major credit cards, checks, and money orders are
accepted. Cash is not accepted at the State Operated Fingerprinting Centers.
Biometrics Identity Verification System
5010 Sunnyside Avenue, Suite 300
Beltsville, MD 20705
301.477.3210
The location below is available by appointment only:
University of Maryland, College Park
Department of Public Safety Service Building
Rossborough Lane
College Park, MD 20742
Phone: 301.405.5758
All fees must be paid by credit card, check or money order in United States
currency. The Central Repository cannot accept cash.
Full background [state and FBI]
for authorized agencies only
$34.50
State background check only
$18.00
The fingerprinting fee at the CJIS Central Repository is $20.00 with no card limit. You
may choose to have your fingerprints taken at another agency. Make sure to check with
that agency for their fingerprinting fees as fees may vary.
The total fee for "State background check only" is $38.00
Mic Homecare Services authorization number is # 1400001293. Be sure to enter this number on
the Livescan Pre-registration Application form so that CJIS will email your report directly to us.
4920 Niagara Rd Ste 116, College Park MD 20740
Email: [email protected]
Phone: 301-486-4502 Fax: 301-486-4503
Website: www.michomecare.com
2
EMPLOYMENT APPLICATION FORM
PART A: PERSONAL INFORMATION
Title: Mr. /Miss /Mrs.
Other ( Please specify)
First Name:
Home Address:
Correspondence Address (If different:
Last Name:
Home Telephone:
Work Telephone:
May we contact you at work?
Yes/ No
Are you a citizen of the United States? Yes/ No
Date of Birth:
If no, are you eligible to work in the United States? Yes/ No
If you are under age 18, do you have an employment/age certificate? Yes ___ No ___
Have you ever been convicted of a misdemeanor or felony? Yes/ No
If yes, please explain the circumstances of the conviction.
AVAILABLE HOURS (in HH:MM format)
SUNDAY MONDAY TUESDAY WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
FROM:
TO:
PART B: EDUCATION AND TRAINING
High School Name and Address
Dates
Attended:
Diploma
Received?
Area of Study
Yes No
Colleges/ Training Schools
Dates
Attended:
Diploma
Received?
Area of Study
Yes No
Professional trainings/ qualifications with dates and levels obtained
4920 Niagara Rd Ste 116, College Park MD 20740
Email: [email protected]
Phone: 301-486-4502 Fax: 301-486-4503
Website: www.michomecare.com
3
PART C: PRESENT AND PAST WORK HISTORY
Present or most
Dates(month/ year) Position Held and Duties:
recent employer
and address:
Starting Salary:
May we contact this employer?
Ending Salary:
If no, please indicate reason.
WORK HISTORY
Give details of your work history with the most recent listed first:
Employer and
Dates (month/
Position Held and Duties:
address:
year)
Starting Salary:
May we contact this employer?
Reason for leaving
Yes/ No
ONE
Reason for leaving
Yes/ No
If no, please indicate reason.
Ending Salary:
WORK HISTORY
Give details of your work history with the most recent listed first:
Employer and
Dates (month/
Position Held and Duties:
address:
year)
Starting Salary:
May we contact this employer?
TWO
Reason for leaving
Yes/ No
If no, please indicate reason.
Ending Salary:
4920 Niagara Rd Ste 116, College Park MD 20740
Email: [email protected]
Phone: 301-486-4502 Fax: 301-486-4503
Website: www.michomecare.com
4
PART D: SUPPORTING STATEMENT
Please indicate all relevant experience, skills and work history that relate to the job description of which you have applied.
Please print clearly. All illegible entries will not be considered.
(attach additional sheets if necessary)
PART E: MEDICAL HISTORY
What absences due to illness have you had from work for the last two years?
Do you have any illness that will present you from performing the duties of the position of which you have applied? Yes/
No
If yes, please indicate
Can you lift a weight of seventy pounds?
Yes/ No
PART F: REFERENCES
Please list three character references of which we may contact.
Name
Relationship
Years of Affiliation
Telephone number
PART G: DECLARATION
By signing below I, _________________________________________, on the date of __________________________,
hereby certify that all information included in the above application is true and valid to the best of my knowledge. I also
understand that misrepresentation or falsification of the information provided above will result in my immediate
disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery.
Name: _____________________________________
4920 Niagara Rd Ste 116, College Park MD 20740
Email: [email protected]
Date:_______________________
Phone: 301-486-4502 Fax: 301-486-4503
Website: www.michomecare.com
5
CONFIDENTIAL AGREEMENT
READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT
I agree that except at the request and for the benefit of Mic Homecare Services I will not disclose to anyone or use for my own
purposes any of Mic Homecare Services confidential or proprietary information, either during or after my employment. I
understand and agree that Mic Homecare Services bidding, costs, pricing and marketing information and techniques, customer
names and information, and employee name and information are confidential and proprietary to Mic Homecare Services.
I certify that this application contains no willful misrepresentation or falsifications and that this information given by me is true
and complete to the best of my knowledge and belief. I authorized Mic Homecare Services to contact all sources to verify the
information on this application. I understand that any falsification, misrepresentation or fraudulent information provided by me in
connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate
discharge.
I understand that this application is not a contract of employment.
I authorize and request my former employers, references, and educational institutions which have information about me, to give
Mic Homecare Services any and all information and opinions about me in their possession and which may lawfully be disclosed.
I hereby waive written notice of such release of information and opinions, and release such former employers, references, and
educational institutions from any liability or claim relating to such release of information and opinions. I also authorized and
request federal, state, and local governmental agencies to release to Mic Homecare Services any information requested,
concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an
original.
Signature of applicant:
Date:
CONFLICT OF INTEREST
4920 Niagara Rd Ste 116, College Park MD 20740
Email: [email protected]
Phone: 301-486-4502 Fax: 301-486-4503
Website: www.michomecare.com
6
I acknowledge that I have read the company policy statement concerning conflict of interest and I hereby declare that neither I,
nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family
has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company
that would constitute a violation of that company policy. Furthermore, I declare that during my employment, I shall continue to
maintain my affairs in accordance with the requirements of said policy.
____________
Signature of Applicant
Date
RELEASE OF INFORMATION
I hereby authorize all prior employers, schools, credit bureaus, Social security Administration. Law enforcement agencies and
investigative agencies to give Mic Homecare Services any and all information concerning my previous employment and any
pertinent information they may have personal or otherwise, concerning my qualifications for the position applied for. I release to
Mic Homecare Services and all its employees form all liability for any damage that may result from furnishing information to
Mic Homecare Services I also release Mic Homecare Services and all its employees from all liability for any damage that may
result from reliance on the information furnished. I understand that if a consumer investigative report is requested, I have the
right under the Fair Credit Reporting Act to request in writing, within a reasonable time, a complete and accurate disclosure of the
nature and scope of the investigation. This written request should be addressed to the location where this application is filed.
Full Name (Please Print)
_ Social Security Number ______ /______/ ______
Signature of Applicant
4920 Niagara Rd Ste 116, College Park MD 20740
Email: [email protected]
Date: _______/ _______/________
Phone: 301-486-4502 Fax: 301-486-4503
Website: www.michomecare.com
7
STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY
LIVESCAN PRE-REGISTRATION APPLICATION
APPLICANT INFORMATION
(PLEASE TYPE OR PRINT CLEARLY)
Name:
Date of birth:
Height:
Race:
ft.
SSN:
inches
Black
Weight:
White
Gender:
lbs.
Eye Color:
)Asian/Pacific
Place of Birth:
Islander
Male
Female
(Please check)
Hair Color:
Native American
Other
(Please check)
Citizenship:
Current address:
City:
State:
Daytime Phone:
Evening Phone:
ZIP Code:
-
Driver’s License #:
AGENCY INFORMATION
Agency Authorization #: 1400001293
ORI # (if required):
Reason fingerprinted?
Position Applied for:
Request Type: (Choose one ONLY)
Adult Dependent Care
Attorney/Client
Child care
Criminal Justice
Gold Seal/ Adoption
Gold Seal/Letter/VISA
Government Employment
Government Licensing or Certification
Immigration/VISA
Individual Challenge
Individual Review
MSP Licensing
Private Party Petition
Public Housing
Mail Response to:
(Mailing option only available for Visa Gold Seal and/or Individual Review)
Name:
________________________________________________________________________________________
Address:
_______________________________________________________________________________________
City, State, Zip code:
______________________________________________________________________________
STATE OF MARYLAND
DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES
CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY
LIVESCAN PRE-REGISTRATION APPLICATION
APPLICANT INFORMATION
(PLEASE TYPE OR PRINT CLEARLY)
Name:
Date of birth:
Height:
Race:
ft.
SSN:
inches
Black
Weight:
White
Gender:
lbs.
Eye Color:
)Asian/Pacific
Place of Birth:
Islander
Male
Female
(Please check)
Hair Color:
Native American
Other
(Please check)
Citizenship:
Current address:
City:
State:
Daytime Phone:
Evening Phone:
ZIP Code:
-
Driver’s License #:
AGENCY INFORMATION
Agency Authorization #: 1400001293
ORI # (if required):
Reason fingerprinted?
Position Applied for:
Request Type: (Choose one ONLY)
Adult Dependent Care
Attorney/Client
Child care
Criminal Justice
Gold Seal/ Adoption
Gold Seal/Letter/VISA
Government Employment
Government Licensing or Certification
Immigration/VISA
Individual Challenge
Individual Review
MSP Licensing
Private Party Petition
Public Housing
Mail Response to:
(Mailing option only available for Visa Gold Seal and/or Individual Review)
Name:
________________________________________________________________________________________
Address:
_______________________________________________________________________________________
City, State, Zip code:
______________________________________________________________________________