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APPLICATION FORM

Employment Application

Employment Application

Pace Staffing Home Healthcare is an equal opportunity employer. We are committed to providing fair and equitable employment opportunities to all qualified applicants and employees. We do not discriminate on the basis of race, color, creed, religion, sex, national origin, age, disability, marital or veteran status, sexual orientation, or any other status protected by law.

Application Instructions:

  • Please complete all sections of the application, even if the information is already listed on your resume or other submitted documents.
  • Be sure to sign and date your application.
  • Clearly state the exact title of the position you are applying for.
  • Type or print all requested information neatly and accurately.
  • Provide contact information for three professional references.
  • You may attach a resume (optional).
1
Personal Information
2
General Information
3
Employment Request
4
Employment History
5
Education
6
Military Service
7
Reference
8
Signature / Certification
9
Submit Application
Personal Information
Current Address
Languages
Please upload PDF, DOC, or DOCX files only (max 16MB)
General Information
Employment Request
Please upload PDF, DOC, DOCX, JPG, or PNG files only (max 16MB)
$
Employment History (Optional)

Please provide your most recent employment information (if applicable):

Education History (Optional)

Please provide your education background information (if applicable):

Military Service
References

Please provide at least one professional reference:

Signature / Certification

I certify that the above is true and correct and give my consent for my name to appear on the Department’s Health Care Worker Registry with the results of my criminal history records check.

I authorize all federal and state agencies, persons, and organizations that may have information relevant to this research to disclose such information to Pacestaffing Homecare Inc. or its authorized agent(s).

I understand that this authorization is to be part of the written and signed employment application.

I also understand that I do not have to give authorization for a background check, but if I don't give permission, my employment application will not be processed further.

I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.

I further authorize that a photocopy of this authorization may be considered as valid as the original.

I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with Kaff Homecare Inc. is contingent upon the successful completion of a background check.

Authorization and Disclosure for Criminal History Records Information (CHRI) Check

I hereby authorize the Illinois Department of Public Health (the Department), the Department’s designee, educational entities that train and/or test health care workers, staffing agencies, my current or potential employer, or a health care facility where I want to volunteer to initiate/request a CHRI check on me. I further authorize the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI) to release information relative to the existence or nonexistence of any criminal record, which it might have concerning me, to any initiator/requestor solely to determine my suitability for training or testing in a health care training program, employment, continued employment, or to work as a volunteer. I further authorize any entity that maintains criminal records relating to me, including but not limited to a local unit of government in any State, to release those records to the ISP, FBI, or the Department. I authorize the Department to provide any health care facility, training program or staffing agency, to which I have provided this authorization and disclosure form, a copy of my ISP CHRI and a determination of eligibility of the FBI CHRI. I certify that the ISP, FBI, any entity that maintains criminal records, the Department, and any of their employees or officers who furnish this information shall be held harmless from all liability, which may be incurred as a result of releasing such information. I further acknowledge that an educational entity or health care employer shall not be liable for the failure to hire or retain me as an applicant, student, employee, or volunteer if I have been convicted of committing or attempting to commit one or more of the offenses stated in the Health Care Worker Background Check Act (225 ILCS 46/25).

I understand that any false statements or deliberate omissions on this document may be grounds for disqualification from employment, training, or volunteering, if discovered after employment, training, or volunteering begins, and can result in discipline up to and including my termination of employment, being a volunteer, or a student.

I understand that the information requested below regarding gender, race, height, eye color, hair color, weight, place of birth and date of birth is for the sole purpose of identification and the accurate gathering of the criminal history record information, and that it will not be used to discriminate against me in violation of the law. I understand that the provision of my Social Security number is required by law. A facsimile or photographic copy of this authorization will be as valid as the original.

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Application Complete

Review Your Application

Please review all the information you have provided before submitting your application.