| Have you ever been convicted of a felony? |
|
| If yes, please explain: |
|
| In case of emergency, please notify: |
Name:
Address:
Phone #:
|
| |
|
"I certify that the facts contained in this application are true and complete to the best of my knowledge and 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 to Danville Services of NV, LLC (Danville) 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 the same to Danville.
Danville is an At Will Employer, which means that employment with Danville is for an unspecified duration and that this employment relationship may be terminated at any time for any reason or no reason with or without cause and with or without notice either by the employee or employer.
" |
|
I agree to the above statement. |
| |
Danville Services of Nevada, LLC
EMPLOYEE STATEMENT PERTAINING TO
BACKGROUND CHECKS
Criminal Background
I agree to allow Danville Services of Nevada, LLC to request background verification with the State of Nevada Criminal History Repository. Only “negative” responses are qualified to continue employment. I agree to the above statement.
Driving Background
I also understand that in order to work in a position that required driving company vehicles or transporting individuals, I must be at least 21 years of age, possess a valid NV DL and have a driving record with no DUI’s or suspensions, and with no more than 3 moving violations. I understand that failure to meet the driving requirements could jeopardize my position with Danville Services of Nevada, LLC. I agree to the above statement.
Release of Information
The release of any and all information is authorized whether same is of record or not, and I do hereby release all persons, firms, agencies, companies, groups or installations whomsoever, from any damages of, or resulting from, furnishing such information to Danville and the insurance company. I agree to the above statement.
If hired, I accept employment understanding the above conditions.
I agree to the above statement.
|
Danville Services of Nevada, LLC
EMPLOYEE STATEMENT PERTAINING TO
BACKGROUND INVESTIGATION
NRS 449.188
- Murder, voluntary manslaughter or mayhem.
- Assault with intent to kill or commit sexual assault or mayhem.
- Sexual assault, statutory sexual seduction, incest, lewdness, indecent exposure, or any other sexually related crime.
- Abuse or neglect of child or contributory delinquency.
- Violation of any federal or state law concerning the possession, distribution or any use of any controlled substance or any dangerous drug within the past 7 years.
- Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property within the past 7 years.
- A violation of any provision of NRS 200.50955/5099 (abuse, neglect, exploitation or isolation of an older person or a vulnerable person.)
- Any other felony involving the use of a firearm or other deadly weapon within the immediately preceding seven years.
By checking this box, I am stating that I do not have any of the above convictions on record
I understand that two sets of fingerprints will be taken and submitted to the Central Repository for a state and federal review. I authorize my employer to deduct $22.50 (less than 1/2 the cost) from my first paycheck. If any of the above crimes are found in my background, I will be subject to termination.
|
CPR/FIRST AID TRAINING STATEMENT
I understand that if hired, I must have proof of CPR/1st Aid certification on the date of my orientation. Danville Services of NV, LLC offers a paid training on orientation day. |
| I have proof of current CPR which expires on: |
|
| I have proof of current 1st Aid which expires on: |
|
| I authorize my employer to deduct $10 for CPR training |
|
| I authorize my employer to deduct $10 for 1st Aid training |
|
Pre-Screening Questions
(To be completed by all applicants) |
| The position you are applying for may require driving: |
| The position you are applying for may require driving: |
|
| Do you have a DL from another state? (you are required by law to get a NV DL within 30 days of residency) |
|
Are you at least 21? |
|
Do you have more than 3 moving violations? Record of driving on suspended license or have a DUI? |
|
Do you have a reliable, safe, registered and insured vehicle? |
|
| Do you have any education or training in this field? |
|
| This job may include supporting a person with personal hygiene that may include
assistance in the restroom and bathing. Once trained, would you be comfortable
supporting a client with these tasks? |
|
| Please give a brief example of how you could support a person with a physical disability while preparing a meal. |
|
| Have you ever been involved in an allegation of abuse, neglect or exploitation where the findings were substantiated? |
|
| Does your name appear on any abuse or sex offender registry? |
|
| Do you have the ability and interest to perform all expectations of the applicable job description? |
|
| How did you hear about the position? |
|
APPLICANT: Please complete boxed section only and return with application. Danville will complete the reference check process
REQUEST FOR EMPLOYMENT INFORMATION
COMPLETE ALL FIELDS –ASK THE ADMINISTRATIVE ASSISTANT FOR A PHONE BOOK IF NECESSARY
|
| Last Four Digits of SSN |
|
| Name |
|
| Company you worked for: |
|
| Supervisor’s Name: |
|
| Company Address: |
|
| Company Telephone: |
|
| Dates of Employment: |
|
| Position: |
|
| Having made application with Danville Services of NV, LLC, I hereby authorize the release of information directly to said Company. I release and hold harmless present and past employers, references and all persons and institutions whomsoever, from any charge because of furnishing information. I waive any application to the Family Education and Privacy Act insofar as the same might apply to responding to this request for information. |
|
I agree to the above statement. |
|
|
