EMPOWERED COMMUNITY LIVIING LLC - Empowered Community Living

EMPOWERED COMMUNITY LIVIING LLC - Step 1 of 18

EMPOWERED COMMUNITY LIVIING LLC

Employment Application

Applicant Information

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Last Name

First Name

M.l

Date

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Address

Apartment/Unit

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City

State

ZIP Code

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Phone

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Date Available:

Social Security No:

Desired Salary:

Position Applied for:

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Are you a citizen of the United States?

If no, are you authorized to work in the U.S.?

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Have you ever worked for this company?

Have you ever been convicted of a felony?

If yes, when?

If yes, explain:

Education

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High School:

Address:

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From

Did you graduate?

Diploma:

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College:

Address:

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From:

To:

Did you graduate?

Degree:

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Other:

Address:

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From:

To:

Did you graduate?

Degree:

References

Please list three professional references.

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Full Name:

Company:

Relationship:

Phone:

Address:

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Full Name:

Company:

Relationship:

Phone:

Address:

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Full Name:

Company:

Relationship:

Phone:

Address:

Previous Employment

Please list three professional references.

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Company Name:

Address:

Phone:

Supervisor:

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Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

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Form:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

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Company Name:

Address:

Phone:

Supervisor:

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Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

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Form:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

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Company Name:

Address:

Phone:

Supervisor:

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Job Title:

Starting Salary:

Ending Salary:

Responsibilities:

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Form:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference?

Military Service

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Branch:

From:

To:

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Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

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Signature:

Date:

ATTESTATION OF GOOD MORAL CHARACTER

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Employee/Applicant/Contractor/Volunteer Name:

By signing this form, I affirm and attest that I meet the Moral Character requirements for employment as required pursuant to Chapter 435, Florida Statutes, and Section 393.0655, Florida Statutes.

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EMPOWERED COMMUNITY LIVING LLC

Provider/Employer Name:

I have not been arrested with disposition pending or found guilty of regardless of adjudication, or entered a plea of nolo contendre (no contest) to or have been adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction for any of the offenses listed below.

Criminal Offenses listed in section 435.04, F.S.

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(a) Section 393.135, relating to sexual misconduct with certain developmental disabled clients and reporting of such sexual misconduct.
(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.
(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.
(d) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection.
(e) Section 782.04, relating to murder.
(f) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.
(g) Section 782.071, relating to vehicular homicide.
(h) Section 782.09, relating to killing of an unborn quick child by injury to the mother.
(i) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.
(j) Section 784.011, relating to assault, if the victim of the offense was a minor.
(k) Section 784.03, relating to battery, if the victim of the offense was a minor.
(l) Section 787.01, relating to kidnapping.
(m) Section 787.02, relating to false imprisonment.

(n) Section 787.025, relating to luring or enticing a child.
(o) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.
(p) Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person.
(q) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.
(r) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.
(s) Section 794.011. relating to sexual battery.
(t) Former s. 794.041. relating to prohibited acts of persons in familial or custodial authority.
(u) Section 794.05, relating to unlawful sexual activity with certain minors.
(v) Chapter 796, relating to prostitution.
(w) Section 798.02, relating to lewd and lascivious behavior.
(x) Chapter 800, relating to lewdness and indecent exposure.
(y) Section 806.01, relating to arson.
(z) Section 810.02, relating to burglary.

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(aa) Section 810.14, relating to voyeurism, if the offense is a felony.
(bb) Section 810.145. relating to video voyeurism, if the offense is a felony.
(cc) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.
(dd) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.
(ее) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.
(ff) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.
(gg) Section 825.103, relating to felony offenses for the exploitation of an elderly person or disabled adult.
(hh) Section 826.04. relating to incest.
(ii) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.
(jj) Section 827.04, relating to contributing to the delinquency or dependency of a child.
(kk) Former s. 827.05, relating to negligent treatment of children.
(II) Section 827.071, relating to sexual performance by a child.
(mm) Section 843.01, relating to resisting arrest with violence.
(nn) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.

(oo) Section 843.12, relating to aiding in an escape.
(pp) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institution.
(qq) Chapter 847, relating to obscene literature.
(rr) Section 874.05, relating to encouraging or recruiting another to join a criminal gang.
(ss) Chapter 893, relating to drug abuse prevention and control if the offense was a felony or if any other person involved in the offense was a minor.
(tt) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting requirements for such sexual misconduct.
(uu) Section 944.35(3). relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.
(vv) Section 944.40, relating to escape.
(ww) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.
(xx) Section 944.47, relating to introduction of contraband into a state correctional facility.
(yy) Section 985.701, relating to sexual misconduct in juvenile justice programs.
(zz) Section 985.711, relating to contraband introduced into detention facilities

435.04(3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction.

Section 393.0674(2). felony offenses for the release or use of information from juvenile records of the Agency for Persons with Disabilities for any purpose other than screening for employment

Criminal Offenses listed in section 393.0655 (5), F.S.

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(a) Any authorizing statutes, if the offense was a felony.
(b) This chapter, if the offense was a felony.
(c) Section 409.920, relating to Medicaid provider fraud.
(d) Section 409.9201, relating to Medicaid fraud.
(e) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.
(f) Section 817.234, relating to false and fraudulent insurance claims.
(g) Section 817.505, relating to patient brokering.
(h) Section 817.568. relating to criminal use of personal identification information.

(i) Section 817.60. relating to obtaining a credit card through fraudulent means.
(j) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.
(k) Section 831.01, relating to forgery.
(l) Section 831.02, relating to uttering forged instruments.
(m) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.
(n) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.

The following acknowledgements apply to all Direct Service Providers and/or Employees, Contract Providers, and Volunteers. Please initial each statement.

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I affirm that I have not been designated as a sexual predator pursuant to s. 775.21; a career offender pursuant to s. 775.261; or a sexual offender pursuant to s. 943.0435, unless the requirement to register as a sexual offender has been removed pursuant to s. 943.04354.

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I understand that I must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any similar statute of another jurisdiction, regardless of whether or not those records have been sealed or expunged.

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I understand that, while employed or volunteering in any position that requires an APD background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest, any notice of possible criminal prosecution including any violation or infraction mandating a court appearance. Reporting must be done immediately if during normal working hours or immediately the next business day if after normal working hours.

ONE OF THE FOLLOWING STATEMENTS MUST BE SIGNED:

I attest that I have read the above carefully and state that my attestation here is true and correct and that my record does not contain any of the above listed offenses. I understand, under penalty of perjury, all employees in such positions of trust or responsibility shall attest to meeting the requirements to the background screening standards set forth in Chapter 435 and Section 393.0655.

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Signature of Affiant:

Date:

My record contains one or more of the applicable disqualifying acts or offenses listed above.

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Signature of Affiant:

Date:

Note: If you have previously been granted an APD exemption for this disqualifying offense, a copy of the APD exemption letter must be attached.

I am a licensed physician, licensed nurse, or other professional licensed and regulated by the Department of Health. I will be holding a position that is within the scope of my licensed practice, and I am not subject to the screening provisions of section 393.0655, Florida Statutes.

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Signature of Affiant:

Position for Provider/Employer listed on pg. 1

Date:

PROVIDER APPLICANT REFERENCE FORM

The applicant below has applied to become a Medicaid Waiver Provider. Your cooperation in completing this reference will greatly assist the Agency for Persons with Disabilities (APD) in determining if the applicant meets the minimum qualifications to become a Waiver Provider.

INSTRUCTIONS:

Please type or print legibly.
Applicants must have references from two (2) supervisors or co-workers who are familiar with their work in a Developmental Disability setting.
APPLICANT - Complete Part I, provide this form to your references with a return self-addressed envelope. Provide the completed form from your reference with your application materials.
REFERCTCE - Complete Part II and return this farm to the applicant in the envelope provided to you.

PART I - APPLICANT

Name:

PARTII-REFERENCE

REFERENCE NAME:

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ADDRESS

CITY

STATE

ZIP

Phone:

OTHER CONTACT INFORMATION:

RELATIONSHIP TO APPLICANT:

SUPERVISOR
CO-WORKER

DATES OF RELATIONSHIP:

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FROM:

TO:

PROFESSIONAL POSITION WHEN WORKING WITH APPLICANT:

Title:

Agency/Institution:

Address:

RECOMMENDATION:

Recommend
Do Not Recommend the Applicant for Enrollment

ADDITIONAL COMMENTS:

[Please write any comments that would assist the APO Enrollment Liaison in making a decision on this Applicant for enrollment.]

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Reference Signature:

Date:

PROVIDER APPLICANT REFERENCE FORM

INSTRUCTIONS:

Please type or print legibly.
Applicants must have references from two (2) supervisors or co-workers who are familiar with their work in a Developmental Disability setting.
APPLICANT - Complete Part I, provide this form to your references with a return self-addressed envelope. Provide the completed form from your reference with your application materials.
REFERCTCE - Complete Part II and return this farm to the applicant in the envelope provided to you.

PART I - APPLICANT

Name:

PARTII-REFERENCE

REFERENCE NAME:

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ADDRESS

CITY

STATE

ZIP

PHONE:

OTHER CONTACT INFORMATION:

RELATIONSHIP TO APPLICANT:

SUPERVISOR
CO-WORKER

DATES OF RELATIONSHIP:

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FROM: (copy)

TO: (copy)

PROFESSIONAL POSITION WHEN WORKING WITH APPLICANT:

Title:

Agency/Institution:

Address:

RECOMMENDATION:

Recommend
Do Not Recommend the Applicant for Enrollment

ADDITIONAL COMMENTS:

[Please write any comments that would assist the APO Enrollment Liaison in making a decision on this Applicant for enrollment.]

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Reference Signature:

Date:

W-9

Please complete the W-9 Form and then right-click and save. Please upload this form after filling it out and saving it.

Upload Your Filled W - 9 Form Here......

Click or drag a file to this area to upload.

USCIS Form

Please complete USCIS Form 1-9, then right-click and save. Upload this form after filling it out and saving it.

Upload Your Filled USCIS Form Here......

Click or drag a file to this area to upload.

Empowered Community Living LLC, herein referred to as ECL, agrees to furnish the undersigned Employee with certain confidential or proprietary information and forms, including relating to ideas, services or products, for the purposes of performing employee responsibilities and/or determining an interest in providing, developing, selling and/or joint venturing;

WHEREAS Employee agrees to review, perform, examine, learn, inspect or obtain such confidential information only for the purposes described above, and to otherwise hold such information confidential according to the terms of this Agreement.

BE IT KNOWN, that ECL has furnished or shall furnish to Employee certain confidential information and may further allow Employee the right to discuss or interview representatives of ECL on the following conditions:

1. Employee agrees to hold confidential or proprietary information or trade secrets ( confidential information") in trust and confidence and agrees that it shall be used only for the contemplated purposes, shall not be used for any other purpose, or disclosed to any third party.
2. No copies will be made or retained of any written information or prototypes supplied without the permission of ECL.
3. At the conclusion of any employment or discussions, or upon demand by ECL, all confidential information, including manuals, handbooks, name tags, prototypes, written notes, photographs, sketches, models, or memoranda, shall be returned to ECL.
4. Confidential information shall not be disclosed to any employee, client, consultant or third party, unless they agree to execute and be bound by the terms of this Agreement, and have been approved by ECL, and unless ECL agrees in advance that such disclosure is appropriate.
5. This Agreement and its validity, construction and effect shall be governed by the laws of the State of Florida.

Agreed, accepted, and signed as of the date written below.

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Employee/ Contractor:

Date:

EMPOWERD COMMUNITY LIVING, LLC

Signed Policy and Procedures

In effect: (Date) until further notice

I have read and been informed about the content, requirements, and expectations of the policy and procedures for employees at Empowered Community Living, LLC. I have received a copy of the policy and agree to abide by the policy guidelines as a condition of my employment and my continuing employment at Empowered Community Living, LLC.

I understand that if I have questions, at any time, regarding the policies, I will consult with my immediate supervisor or my Human Resources staff members.

Please read the handbook carefully to ensure that you understand the policies and procedures before signing this document.

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Employee Signature:

Employee Printed Name:

Receipt By:

Date:

I acknowledge that I have received a copy of the privacy policies from the Florida Department of Law Enforcement and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the Care Provider Background Screening Clearinghouse.

I understand and agree that I will read and comply with the guidelines contained in the privacy policies.

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Employee/Contractor Name (Printed):

Employee/Contractor Signature:

Date:

FLORIDA DEPARTMENT OF LAW ENFORCEMENT

NOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE CRIMINAL RECORD RESULTS WILL BECOME PART OF THE CARE PROVIDER BACKGROUND SCREENING CLEARINGHOUSE

NOTICE OF:

SHARING OF CRIMINAL HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES,
RETENTION OF FINGERPRINTS,
PRIVACY POLICY, AND
RIGHT TO CHALLENGE AN INCORRECT CRIMINAL HISTORY RECORD

This notice is to inform you that when you submit a set of fingerprints to the Florida Department of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal history records that may pertain to you, the results of that search will be returned to the Care Provider Background Screening Clearinghouse. By submitting fingerprints, you are authorizing the dissemination of any state and national criminal history record that may pertain to you to the Specified Agency or Agencies from which you are seeking approval to be employed, licensed, work under contract, or to serve as a volunteer, pursuant to the National Child Protection Act of 1993, as amended, and Section 943.0542, Florida Statutes. "Specified agency" means the Department of Health, the Department of Children and Family Services, the Division of Vocational Rehabilitation within the Department of Education, the Agency for Health Care Administration, the Department of Elder Affairs, the Department of Juvenile Justice, and the Agency for Persons with Disabilities when these agencies are conducting state and national criminal history background screening on persons who provide care for children or persons who are elderly or disabled. The fingerprints submitted will be retained by FDLE and the Clearinghouse will be notified if FDLE receives Florida arrest information on you.

Your Social Security Number (SSN) is needed to keep records accurate because other people may have the same name and birth date. Disclosure of your SSN is imperative for the performance of the Clearinghouse agencies' duties in distinguishing your identity from that of other persons whose identification information may be the same as or similar to yours.

Licensing and employing agencies are allowed to release a copy of the state and national criminal record information to a person who requests a copy of his or her own record if the identification of the record was based on submission of the person's fingerprints. Therefore, if you wish to review your record, you may request that the agency that is screening the record provide you with a copy. After you have reviewed the criminal history record, if you believe it is incomplete or inaccurate, you may conduct a personal review as provided in s. 943.056, F.S., and Rule 11C8.001, F.A.C. If national information is believed to be in error, the FBI should be contacted at 304-625-2000. You can receive any national criminal history record that may pertain to you directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34. You have the right to obtain a prompt determination as to the validity of your challenge before a final decision is made about your status as an employee, volunteer, contractor, or subcontractor.

Until the criminal history background check is completed, you may be denied unsupervised access to children, the elderly, or persons with disabilities.
The FBI’s Privacy Statement follows on a separate page and contains additional information.

Here are two good insurance companies that cover your line of work:

1. CM&F Group Inc. - www.cmferoup.com CNA or HHA $86.00 per year.

2. Nurse Services Organization (NSO) - www.nso.com HHA $94.00 per year.

3. Please note you are free to sign on with any insurance carrier as long as it is General Liability Insurance of $500,000.

4. Most insurance carriers offer low monthly payment plans.

WAIVER OF LIABILITY INSURANCE

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Name

, am operating as an

Independent Contractor for Empowered Community Living, LLC. This does not create any employee/employer relationship, agency, joint venture, partnership, or any other kind of relationship between Empowered Community Living, LLC and myself other than an Independent Contractor relationship. As an Independent Contractor, I understand and agree that I am responsible for securing my own liability insurance to protect myself against liability arising from injury or death during the course of the work performed. As an Independent Contractor, I understand that Empowered Community Living, LLC does not insure me individually or collectively. I further understand and agree that it is my sole responsibility to secure and maintain life, health, and medical insurance or other financial resources to pay for any injury, illness, or death I may suffer while performing services under this agreement. As an Independent Contractor, I shall hold harmless Empowered Community Living, LLC and their respective officers, directors, employees, and representatives from any and all liability, judgment, loss, damage, claim, cause or causes of action, debt, charge, cost, and expense (including attorney’s fees) arising out of, connected with, or incidental to any action or failure to act by be under this agreement.

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Contractor:

Address:

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Phone:

Email:

Tax ID / SS #

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Signature

Date

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