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****Circle YES or NO to each of the following and explain if necessary****

Have you worked for CCSI before?

If yes, listing previous Job/Title/Location & Length of service

Are you requesting to care for a family member?

Are you at least 18 years of age?

Have you ever had your license suspended or revoked?

Have you ever been convicted of a criminal offense including convictions of minor traffic violation?

I have read and reviewed the list of IDPH Health Care Worker Background Check disqualifying offenses presented to me by CCSI. Applicant agrees that all of the above statements are true and complete to the best of his/her knowledge.

Community Care Systems, Inc. shall not knowingly hire any individual in a position with duties involving direct care for residence if that person has been convicted of committing or attempting to commit one or more of offences listed on the IDPH Health Care Worker Background Check act. All applicants will be subject to screening for such “disqualifying offenses.” Any interviews and/or conditional job offers are contingent upon the outcome of the screening process for “disqualifying offenses” under the act.”

EDUCATION

Did you Graduate?

or Did you receive your GED?

OTHER QUALIFICATIONS

SPECIAL SKILLS AND QUALIFICATIONS: Summarize special job-related skills and qualifications acquired from employment or other experience including volunteer work.

JOB OR COURSE EXPERIENCES

DATES

SKILLS

PRIVATE CARE

DATES

DUTIES PERFORMED

LIST MOST RECENT JOB (FIRST)

EMPLOYER(1)

EMPLOYER(2)

EMPLOYER(3)

REFERENCES: You must provide a minimum of 3 references. Please click here for our Work Reference form and here for our Personal Reference form. Please fill them out and bring them to your interview.

I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.