Office JOB APPLICATION Step 1 of 8 - Applicant Statement and Agreement 12% Date(Required) Position(Required)Please read the paragraph below. If there is anything that you do not understand, please ask. I hereby authorize the Company to thoroughly investigate my references, work record, education, and other matters related to my suitability for contract work and, further, authorize the prior employers/contractors and references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure. In the event of my contracting with the Company, I understand that I am required to comply with all rules and regulations of the Company. I understand that safety is extremely important to the Company and that the Company is committed to ensuring a safe working environment. I understand that I have a responsibility to prevent accidents and injuries by observing all safety procedures. I understand and agree to comply with federal, state, and local regulations related to safety and health. I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I understand that if I am selected for the contract, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States and that federal immigration laws may require me to complete an I-9 Form in this regard. I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable. I understand that I am not allowed to provide two different services during the same period of time for the same or different client(s). I understand that I can not provide services to any person who is related to me by blood. I also understand that in the event that I do provide services to any person related to me by blood my provider could be revoked. I authorize MG Home Care to share personal and confidential information for supervision purposes to the BCaBA/BCBA assigned. Consent(Required) I attest to the fact that I have read, understand, and agree to all of the above terms. Name(Required) First Middle Last DOB(Required) Phone(Required)Email(Required) SSN(Required)Driver License NumberAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1. Have you ever used another name?(Required) Yes No 2. Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?(Required) Yes No 2a. Please explain(Required)3. Have you ever worked for this company before?(Required) Yes No 3a. If yes, please give dates and position(Required)4. Do you have friends and/or relatives working for this company?(Required) Yes No 4a. Please enter name and relationships.(Required)5. On what date are you available to begin to work?(Required) 6. If hired, would you have a reliable means of transportation to and from work?(Required) Yes No 7. Can you travel if the position requires it?(Required) Yes No 8. If contracted, can you present evidence of your identity and legal right to work in this country?(Required) Yes No Emergency Contact #1Name(Required) First Last Relationship(Required)Phone(Required)Email Emergency Contact #2Name(Required) First Last Relationship(Required)Phone(Required)Email Have you ever been involuntarily terminated or asked to resign from any job?(Required) Yes No Please explain(Required)Please explain any gaps in your employment history.Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment. Staff Code of Conduct/Ethics/Conflict of Interest To outline a standard of conduct for all employees, contractors and members of the Board of Directors. To establish and retain the highest possible level of public confidence. CODE OF ETHICS: The Code of Ethics contains standards of ethical behavior and practices that impact all dealings with colleagues, patients, the community and society as a whole. The Code of Ethics also incorporates standards governing personal behavior particularly when that conduct directly relates to the role and identity of the organization. The Code of Ethics outlines principles focused on maintaining and enhancing excellence within OUR AGENCY The Code of Ethics serves as notice to government officials that OUR AGENCY expects its personnel to abide by all applicable laws and regulations. OUR AGENCY has an ethical responsibility to the patients and the community it serves, and fulfills this responsibility through ethical care, treatment, services and business practices. Whenever possible, patients/families/legal guardians are included in decisions about the patients' care, treatment and services, including ethical issues. Should the patient require or request care, treatment or services not available or inconsistent with the organization's mission, an offer to refer/transfer the patient to an organization that can fulfill this need will be made and if in agreement, the patient will be referred/transferred appropriately. The patient/family will be notified of any financial benefit, if any, to OUR AGENCY as a result of the referral/transfer process. Contracted providers/staff of healthcare services must meet and adhere to the quality and ethical standards of this organization. Billing practices of OUR AGENCY shall adhere to and be compliant with usual and acceptable standard ethical and legal business billing practices. The effectiveness and safety of care, treatment and services provided by OUR AGENCY is consistent for all patients and is not dependent on the patient's ability to pay. STAFF MEMBERS' AND BOARD OF DIRECTORS' RESPONSIBILITY TO THE ORGANIZATION: Uphold the values, ethics and mission of the organization. Conduct all personal and professional activities with honesty, integrity, respect, fairness and good faith in a manner that will reflect positively upon the organization and in the best interest of the patient population and community served. Comply with all applicable local, state and federal laws and regulations in the conduct of organizational or personal activities. Respect confidences including confidential business information. Assure that no conflict of interest exists in any dealings involving the organization. Provide healthcare services consistent with available resources and assure the existence of a resource allocation process that considers ethical ramifications. Respect of the customs and practices of those served, consistent with the organization's philosophy. Be truthful in all forms of communication, including receivables and avoid information that would create unreasonable expectations. Assure the existence of a process to evaluate the quality of care or services rendered. Avoid practicing or facilitating discrimination and institute safeguards to prevent discriminatory organizational practices. Advise patient of rights, responsibilities and risks regarding care and services provided. Conflict of Interest PURPOSE: To ensure employees avoid any personal interest that may conflict with the interests of the agency. POLICY: The Agency expects all of its employees to understand and be aware of potential situations where their personal interests may conflict with the business interests of the Agency. PROCEDURE: All employees will report to their immediate supervisor any interests in or employment with an entity that interacts with the Agency including, but not limited to: employee participation in any business transactions where there might appear to be a conflict between the employee's personal interest and that of the Agency. employee participation in any entity which buys services from or provides services/products to the Agency. outside employment that interferes with satisfactory performance of an employees duties and responsibilities for the Agency. any outside relationship, financial interest, or participation in a business transaction which might appear to influence the performance of an employee's duties and responsibilities for the Agency. acceptance/giving of gifts, including cash payments, fees, services, discounts, valuables, privileges or other favors which would or might appear to improperly influence an employee in the performance of the employee's duties and responsibilities for the Agency. If a conflict of interest is discovered or suspected the supervisor/manager and employee will discuss its impact with the Administrator. After the above discussion, a recommendation may be made for the employee to end his/her association with the entity or the Agency within a specified period of time. The failure of an employee to cease activity that management determines to be a conflict interest will subject the employee to disciplinary action up to and including termination. Upon hire, agency staff will sign a Conflict of Interest Statement. VIOLATIONS: Employees, Administrators and volunteers who violate this code shall be subject to disciplinary action, up to and including termination of employment. Explain any possible conflict of interest (Example working for another Agency, Hospital, etc): Please list the names of your present or previous employers/contractors in chronological order, with the most recent employers/contractors listed first. Be sure to account for all periods of time. If self-employed, give the firm name and supply business references.Employer #1Name of EmployerSupervisor's NamePhoneMay we contact them? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates Employed (From) Dates Employed (To) Job Title and DutiesReason for LeavingEmployer #2Name of EmployerSupervisor's NamePhoneMay we contact them? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates Employed (From) Dates Employed (To) Job Title and DutiesReason for Leaving Please visit the following link to read the latest version of MG Home Care's Independent Contractor Agreement. Consent(Required) I’ve read this agreement carefully and understand its terms and conditions.Please visit the following link to read the latest version of MG Home Care's Confidentiality and Non-disclosure Policy.Consent(Required) By clicking this link I agree that I've read this agreement.Initials(Required)Signature(Required)Your NameYour NameYour NameYour Name
