Domus Vita, Inc. is an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, sex, religion, national origin, marital status, age, weight, height, color or handicap, in the hiring promotion, payment or discipline of employees.

If you are a person with a handicap, you may request any needed reasonable accommodation to participate in the application process or interview process. This request should be made in advance so that we can make accommodation.

We will not discriminate against a person with a covered disability under the Americans With Disabilities Act in regard to employment practices, or terms, conditions, and privileges of employment.

* Social Security Number - last 4 digits only:

* I currently have a valid driver’s license.

Yes   No

* Have you had 3 or more moving violations in the last 3 years?

Yes   No

* I am 18 years of age or older.

Yes   No

* I can perform the duties of the job with or without accommodation:

Yes   No

* I understand that Domus Vita provides adult foster care and personal care, often 24 hours a day, 7 days a week, 52 weeks a year.  I also understand that my availability to work overtime hours is expected for continued employment.

Yes   No

* I am able to work overtime.

Yes   No

I am disclosing, by listing below, all offenses for which I have been convicted, including all terms and conditions of sentencing, parole and probation therefore, and/or any substantiated finding of patient or resident neglect, abuse, or misappropriation of property and/or any other substantiated rights violations. I certify that this list is true, correct, and complete to the best of my knowledge.

Offense	Date of Conviction/Finding	City	State	Sentence	Date of Discharge

* Are there any felony charges pending against you?

Yes   No

If yes, please explain.

* Have you ever been employed by Domus Vita, Inc. before?

Yes   No

If yes, give dates employed, and indicate if employed under a different name:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

	School Name or Program	City and State	Did you Graduate?	Degree Received	Grade Point Average
High School General Equivalency Diploma (GED)			Yes   No
Vocational School or College			Yes   No
Vocational School or College			Yes   No
Special Certifications			Yes   No

Give your full employment record, starting with your current or most recent employment

Employer	Phone	Job Title
Address	City	Zip
Dates Worked	Reason Left	Were You Terminated
From: To:		Yes No

Employer	Phone	Job Title
Address	City	Zip
Dates Worked	Reason Left	Were You Terminated
From: To:		Yes No

Employer	Phone	Job Title
Address	City	Zip
Dates Worked	Reason Left	Were You Terminated
From: To:		Yes No

Employer	Phone	Job Title
Address	City	Zip
Dates Worked	Reason Left	Were You Terminated
From: To:		Yes No

Please give two personal references.

Name	Address	City	Zip	Phone
*				*
Name	Address	City	Zip	Phone
*				*

In case of emergency, whom shall we contact?

Name	Address	Phone

I hereby give my permission for Domus Vita, Inc. to contact the above employers, references, and/or educational institutions to verify the information on this application and to inquire as to my work history, education, and character. I release Domus Vita and the above referenced institutions, companies, persons, and employers from all claims, liability and damages that may result from furnishing the information to Domus Vita, Inc. I expressly and fully waive all written notice from all prior employers. I hereby consent to the release of this application or portions of this application to representatives of the State, County and other governmental agencies and to those agencies with which Domus Vita, Inc. contracts to provide services. I further specifically waive written notice and agree to the divulging of any disciplinary action by all prior employers, and hereby release my prior employer from all claims, liability and damages that may result from furnishing the information to you.

I further understand that any dishonest or false answers on this application or in subsequent interview are grounds for or may result in immediate dismissal.

I understand and agree that if I am hired by Domus Vita, Inc. that I will be required to conform to the rules and regulations of Domus Vita, and my employment and compensation can be terminate at-will with or without cause and with or without notice at any time, at the sole discretion of Domus Vita or myself. I agree that no one other than the Executive Director of Domus Vita has any authority to enter into any agreement or contract for a specific period of time or to make any agreement contrary to the foregoing and such contract must be in writing. I further agree that no one other than the Executive Director has the authority to make any changes to this Employment Agreement and such changes shall be in writing and signed by both the Executive Director and me as the employee.

* Signature (type name):

* Date:

Please indicate the shift or shifts you would be willing to work (number 1-4 in order of preferences 1 being most preferred):
Days:
Afternoons:
Midnights:
Split:

* Are you interested in full-time (36-40 hrs)?

Yes   No

* Are you interested in part time (under 36)?

Yes   No

* Can you work weekends?

Yes   No

* Can you work holidays?

Yes   No

* Are there any days you cannot work?

Yes   No

If yes, which ones?

* Are you flexible in your ability to cover shifts as needed?

Yes   No

* Have you received residential training?

Yes   No

If yes, from where? (CLS,   MORC,  NSO, other)

* Do you have a current CPR card?

Yes   No

If yes, date issued:

* Do you have a current First Aid card?

Yes   No

If yes, date issued:

* Did you have a TB test in the last 3 years?

Yes   No

If yes, date completed:

* Have you had a physical in the last year?

Yes   No

If yes, date completed:

* Have you worked in a group home before?

Yes   No

If yes, what type of clients did you work with?

* Do you enjoy taking handicapped or disabled residents on outings?

Yes   No

* Have you assisted anyone with use of their wheel chair?

Yes   No

* Have you assisted with tube feedings?

Yes   No

* Have you assisted persons with Autism?

Yes   No

* Have you assisted persons with Prader-Willi?

Yes   No

* Have you assisted persons with Dementia?

Yes   No

* Have you assisted persons with seizure disorders?

Yes   No

* Have you assisted persons with an ostomy?

Yes   No

* Have you assisted individuals with limited mobility?

Yes   No

* Have you assisted individuals with behavioral issues?

Yes   No

* Do you have any special skills or experience you believe may be relevant to the position you are applying for?

Yes   No

If so please provide a brief description, also indicate if you are Only interested in a management position:

In completing your application, be advised we will need two work references with COMPLETE addresses and phone numbers. Should you be considered for employment you may be sent for a TB test and may be requested to have a drug screen. You may also be required to have a physical examination. The cost of these tests and/or examinations are at the Company's expense.

We offer benefits that will be explained more fully as they become available to you. In general we offer full time employees vacation, personal time, life/dental/health insurance, a tax sheltered annuity program, disability insurance (none of these benefits are fully paid for by the employer and the amounts of employee contribution vary). We pay time-and-a-half for time worked in the home over 40 hours each week and on holidays. We generally do our schedules six weeks at a time and take request for days off prior to completion of the schedule. After the schedule is done, shift switching is allowed with manager approval, but management will generally not adjust the schedule to accommodate your time off. In addition to your regular schedule there may be a monthly staff meeting, if scheduled these meetings are mandatory.

* With all the above, if you are hired, how soon are you available for work?