AREA AGENCY ON AGING OF WESTERN ARKANSAS, INC. 524 GARRISON AVENUE P.O. BOX 1724 FORT SMITH, ARKANSAS (479) Please Print or Type

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1 AREA AGENCY ON AGING OF WESTERN ARKANSAS, INC. 524 GARRISON AVENUE P.O. BOX 1724 FORT SMITH, ARKANSAS (479) Please Print or Type : Name: Social Security Number: Address: Telephone Number: City: State: Zip Code: If you are under 18, can you furnish a work permit? Yes No Have you ever been employed by AAA? Yes No Position for which you are applying? Full Time Part Time Would you be willing to travel? Yes No available to begin work Are you legally eligible for employment in this country? Yes No Have you ever been convicted of a sex-related or child-abuse related crime? Yes No (If yes, explain) (If answering Yes, you will be considered ineligible for employment) Have you ever been convicted of a felony? Yes No (If Yes, explain) (If answering Yes, you will be considered ineligible for employment) Drug tests are required of applicants if a conditional job offer is made. Should applicant fail the drug test or refuse to take the drug test, the offer of employment will be withdrawn. Skills and Qualifications Summarize any training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position which you are applying. Previous Employers s of Job Title Reason for Supervisor Employment Leaving Name Address City/State/Zip Phone From/To Name Address City/State/Zip Phone Name Address City/State/Zip Phone From/To From/To

2 List High Schools, Equivalent GED, Colleges, Vocational or Business Schools School Address Yrs Completed Course of Study Degree/Diploma List Two Employment References Name & Title _ Name & Title Address Address City/State/Zip _ City/State/Zip Business Business Phone Phone List Two Personal References- Not Relatives and/or Employers Name Name Address Address City/State/Zip _ City/State/Zip Phone Phone I hereby certify that the information as stated in this application is true and correct to the best f my knowledge and belief. If accepted for employment I will comply with all personnel policies of this agency. I agree that if I am employed and the information is found to be false, I will be subject to dismissal without notice. The employer does not discriminate in employment on a basis prohibited by local, state, or federal law. I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause, without prior notice. I understand that no representative of the employer has the authority to make any assurance to the contrary. I understand it is this company s policy not to refuse to hire a qualified individual with a disability because of this person s need for an accommodation that would be required by the ADA. I hereby authorize any investigator or duly accredited representative of the Area Agency on Aging of Western Arkansas, Inc., bearing this release to obtain any information from schools, residential management agents, employers, criminal justice agencies or individuals, relating to my activities. This information may include but is not limited to academic, residential, achievement, performance, attendance, personal history, disciplinary, driving record, arrest and conviction records. I hereby direct you to release such information upon the request of the bearer. I understand that if I am employed, the employment will be temporary pending receipt of notification of results of a criminal history check and driving record report. I understand that the information release is for the official use by the Area Agency on Aging of Western Arkansas, Inc., and may be disclosed to such third parties as necessary in the fulfillment of my official responsibilities as an employee of the Area Agency on Aging of Western Arkansas, Inc. I hereby release any individual, including record custodians from any and all liability for damages of whatever kind or nature that may at any time result to me on account of compliance, or any attempts to comply with this authorization. Signature of employee/applicant _

3 PRE EMPLOYMENT DRUG SCREEN All job offers are conditioned upon successful completion of a preemployment drug screening test by an Agency selected laboratory, whereas, the Agency will pay for the testing. If the applicant fails to appear or fails to complete the preemployment drug screening test, that action will be treated as a rejection of the conditional job offer. All medical information provided to the company will be maintained in confidence in accordance with the Americans with Disabilities Act (ADA), the Family and Medical Leave Act (FMLA), state law, and any other applicable law. All applicants will be required to sign the standard consent and release form permitting the laboratory to disclose the results of the drug screening test to the Agency. The form is reproduced at the end of this policy. to humanresources@agingwest.org

4 PREEMPLOYMENT DRUG SCREEN STANDARD CONSENT and RELEASE FORM I,, do voluntarily consent to a preemployment drug screen test conducted at the request of Area Agency on Aging of Western Arkansas, Inc. d/b/a Visiting Nurses Agency of Western Arkansas, Inc. I understand that the offer of employment I have received is conditioned upon the successful completion of the drug screen test. In particular, I understand that if I do not pass the drug screen test, I will not be employed. Additionally, I will be offered the opportunity to provide additional information in response. However, if I do not complete or refuse the drug screen test, I understand that the offer of employment will be withdrawn. I have had the opportunity to ask a representative of the Agency questions about this drug screening test, and any questions I had have been completely and satisfactorily answered. I understand that the cost of the examination will be paid by Area Agency on Aging of Western Arkansas, Inc. d/b/a Visiting Nurses Agency of Western Arkansas, Inc. I consent to the release of the results of this drug screening test to Area Agency on Aging of Western Arkansas, Inc. d/b/a Visiting Nurses Agency of Western Arkansas, Inc. I hereby release and forever discharge Area Agency on Aging of Western Arkansas, Inc. d/b/a Visiting Nurses Agency of Western Arkansas, Inc. and the testing laboratory from any and all claims arising out of or in connection with the drug screen test. Signature of Employee Printed Name Social Security Number Signature of Witness Printed Name Social Security Number

5 AREA AGENCY ON AGING OF WESTERN ARKANSAS, INC d/b/a VISITING NURSES AGENCY OF WESTERN ARKANSAS, INC Employment/Training Reference Inquiry From Title who has applied for a position as, has given your name as a previous employer/trainer from to. We would appreciate your answers to the following questions. I hereby authorize you to issue information regarding my services and character to the agency. I do hereby unconditionally release your organization from all liability for any damages whatsoever which might result from furnishing same. Applicant s Signature 1. The applicant was employed/trained from to 2. Why did applicant leave employment? 3. Would applicant be eligible for rehire? Yes No 4. What were the applicant s responsibilities? 5. Did the applicant provide direct care for patients? (If not applicable, skip part d) (a) Did the applicant provide safe and competent nursing care? Yes No (b) Did the applicant seem to understand the emotional problems of illness and the special requirements of the elderly? Yes No (c) Did the applicant understand what changes in patient s conditions need to be reported? Yes No (d) Did applicant demonstrate the ability to work well with co-workers and other disciplines? Yes No 6. What was your opinion of the applicant as to the following: Personality: Honesty: Initiative: Quality of work: Comments: Signature of person making report

6 Title AREA AGENCY ON AGING OF WESTERN ARKANSAS, INC d/b/a VISITING NURSES AGENCY P.O. BOX 1763 FORT SMITH, AR Please return this form in the envelope provided. _ has applied for a position as a Would you please answer the following questions to the best of your ability? Thank You. 1) Under what conditions do you know this person? 2) Do you know this person to be honest and truthful? 3) Does this person seem mature to you? 4) Do you think that this person would be kind and considerate to all patients? 5) Additional Comments: Signature I hereby authorize you to issue information regarding my services and character to the Agency. I do hereby unconditionally release your organization from all liability for any damages whatsoever which might result from furnishing same. Applicant s Signature