EMPLOYMENT APPLICATION

Suncoast Care Providers Inc. is an opportinityemployer. Applicants are considered without regard to race, color, creed, national origin, region, age, disability, marital status, sexual orientation or any other legally protected status. Applicants who requirereasonable accomodation to completethe applicationand/or interview should notify a representative of Suncoast Care Providers Inc.

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EDUCATION

SUNCOAST CARE PROVIDERS INC (SCP)

Other job-related skills and qualifications:

_____________________________________________________________________

 

____________________________________________________________________

 

 

COMPUTER LITERACY: Check all that apply -- I am ableto use personal computer (without help) for:

 

Data entry

 

Word processing

 

Spread sheet

 

Electronic communications

 

Typing speed________________________wpm.

 

 

Professional References

 

Name	E-mail	Phone No.	Years Known

 

DISCLOSURE AND AUTHORIZATION TO OBTAIN INFORMATION

BACKGROUND SCREENING CONSENT
In connection  with my application for employmentwith Suncoast Care Providers Inc. (SCP), ["Company"], I authorizeSuncoast Care Providers Inc. (SCP) to request a consumer report on me, for employment purposes. Such reports my include , but are not limited to, information as to my charactyer, general reputation, personal characteristics, and mode of living.It may also include my driving history, and my traffic citations,a social securty number trace, present and former addresses,criminal and civil history/records; and any other public record. I hereby authorize without reservation any public or private agency, service bureau, insurace agencies, or other sourcesw public or private, contracted by Suncoast Care Providers Inc. (SCP)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 Suncoast Care Providers Inc. (SCP)or its affiliates , from any of these sources. I agree that this authorization shall remain valid for the duration of my employment with the company.

DRUG-FREE WORKPLACE TESTING CONSENT.
I understand that Suncoast Care Providers Inc. (SCP) 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 such testin or examination at the company'sexpense, at any time during the hiring process and my employment. I understand that my refusalto do so, or certain positive drug screening results may result in Suncoast Care Providers Inc. (SCP)refiusalto hire me or my immediate termination.

NON-DISCLOSURE OF EMPLOYER INFORMATION
I acknowledge that in connection with my application/employment with Suncoast Care Providers Inc. (SCP), I have not been asked to, nor will use, disclose or implement any proprietary information or intellectual property belonging to any previous employer. I acknowledge that I am not currently under any non-compete agreement with a previos employer that would hinder my employment with Suncoast Care Providers Inc (SCP). I understand  that just as I am free to resign at any time, Suncoast Care Providers Inc .(SCP) reserves the right to terminate my employment at any time, with or without cause and without prio notice.

I certify that information contained in this Employment Application Form.is true and correct to the best of my knowledge ; and that my application or employment may be terminated based on any false, omitted or fraudulent  information.



Applicant's Signature:__________________________________                             Date:________________________

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Position(s) applied for:                                                                                             Date of application

 

How did you hear about us?

 

Advertisement              Internet                Friend             Walk-In              Employment Agency      Relative             Other (Specify)_______

____________________________________________________________________________________________

 

What Date Are you available to Start?

____________________________________________________________________________________________

 

Last Name                                                                     Middle Name                                                       MI

 

________________________                                   _________________________                            __________

 

Address

 

____________________________________________________________________________________________

 

City                                                                                State                                                         Zip Code

____________________________________________________________________________________________Previous Address                                                                                                                              How Long ?

__________________________________________________________________________________________________________

Telephone                                             E-mail Address                                                           Sociall Security Number

 

__________________________________________________________________________________________________________

 

Driver's License                    Yes                      No                    State                            Number

 

Have you ever filed an application with us before?                 Yes                No            If Yes, give date_________________

 

Have you everbeen employed in this company before?          Yes              No               If Yes, give date___________________

 

 

Are any of your relatives currently employed by Suncoast care providers Inc. (SCP)        Yes                  No   

 

If Yes, Explain

 

Are you currently employed                                Yes                    No

 

Are you a Citizen of the United States?                Yes                  No

 

A Legal Permanent Resident (Green Card Holder):     Yes           No                      Alien No_________________________

 

Are you 18 years of age or older?                          Yes                  No

 

Are you capable of performing, in a reasonable manner the essential duties of the job for which you are applying         Yes           No              

 

Have you ever been convicted of a felony; entered into a deferred prosecution agreement programs, or had adjudication withheld?  Yes         No

 

If yes, Please explain_________________________________________________________________________________________________

 

Have you ever been excluded, suspended,or debarred from participating in government programs, such as Medicare or Medicaid?      Yes       No

 

If Yes, please explain___________________________________________________________________________________________________

 

 

Person to Contact in case of Emergency

 

Name:

 

Phone:

 

Address:

 

Relationship:

 

 

Employment Experience:  Start with your present or most recent employment'

 

 

                                                             

:1.Employer _____________________________________________________   Address _____________________________________________________ Phone _____________________________________________________ Job Title                 _____________________________________________________ Supervisor _____________________________________________________ Reason for leaving	Dates Employed   From                         To       Hours Rate/Salary   Starting                     Final	Work  Performed
2. Employer _____________________________________________________ Address _____________________________________________________ Phone: _____________________________________________________ Job Title _____________________________________________________ Supervisor _____________________________________________________ Reason for leaving	Dates  Employed   From                  To     Hourly Rate/Salary   Starting                   Final	Work Performed
3.Employer _____________________________________ Address ____________________________________________________ Phone ____________________________________________________ Job Title ____________________________________________________ Supervisor ________________________________________________________-- Reason for Leaving	Dates Employed   From                    To   Hourly Rates/Salary   Starting                  Final	Work Performed
4. Employer _____________________________________ Address _____________________________________________________ Phone _____________________________________________________ Job Title _____________________________________________________ Supervisor _____________________________________________________ Reason for leaving	Dates Employed   From                     To     Hourly Rate/Salary   Starting                   Final	Work Performed