Access Safe Care LLC Employment Application Download, save, and fill out his form, then email to: info@asafecare.com Download Application Form Or fill the application online below Please enable JavaScript in your browser to complete this form. Please enable JavaScript in your browser to complete this form. - Step 1 of 8 Layout Name * First Middle Last Date Today * Street Address * Layout City, State, ZIP * Email * Email Confirm Email Home Phone * Cell Phone Next Layout Position Desired * Salary Expected * I am authorized to work in the United States: * Yes No Layout Do You have a Valid Driver's License? * Yes No State * Has Your Driver's License ever been revoked? * Yes No On what date can you begin? * Layout Are you available to work * Full time Part Time Temporary Can You travel for work if needed? * Yes No Previous Next Monday * 1ST SHIFT (8:00 AM TO 4:00 PM) 2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT) 3RD SHIFT (12:00 AM TO 8:00 AM) Tuesday * 1ST SHIFT (8:00 AM TO 4:00 PM) 2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT) 3RD SHIFT (12:00 AM TO 8:00 AM) Wednesday * 1ST SHIFT (8:00 AM TO 4:00 PM) 2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT) 3RD SHIFT (12:00 AM TO 8:00 AM) Thursday * 1ST SHIFT (8:00 AM TO 4:00 PM) 2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT) 3RD SHIFT (12:00 AM TO 8:00 AM) Friday * 1ST SHIFT (8:00 AM TO 4:00 PM) 2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT) 3RD SHIFT (12:00 AM TO 8:00 AM) Saturday * 1ST SHIFT (8:00 AM TO 4:00 PM) 2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT) 3RD SHIFT (12:00 AM TO 8:00 AM) Sunday * 1ST SHIFT (8:00 AM TO 4:00 PM) 2ND SHIFT (4:00 PM TO 12:00 AM (MIDNIGHT) 3RD SHIFT (12:00 AM TO 8:00 AM) Previous Next Layout Emergency Contact Name * Emergency Contact Telephone: * Relationship? * Do you know of any reason you cannot perform the essential functions of the job for which you are applying with or without reasonable accommodation? * Yes No Layout Have you ever gone by a name other than the one listed above? * Yes No Have you ever been convicted of a crime? * Yes No If yes, please list here: If yes, please, explain and include dates: Layout Have you ever had a substantiated cas brought against you by child and/or adult protective services? * Yes No If yes, please, explain and include dates: Layout Please list all Licenses and certifications you now hold: * DSP CRMA CPR/FIRST AID CPI LCSW LCPC MSW LADC CAN LPN RN MHRT Other: Previous Next High School School Name & Location Course Of Study Year Completed Degree or diploma? College School Name & Location Course Of Study Year Completed Degree or diploma? Graduate School Name & Location Course Of Study Year Completed Degree or diploma? Business/Trade Technical School Name & Location Course Of Study Year Completed Degree or diploma? Previous Next Employment One Employment History Company, Agency name Address Job title Weekly Pay Supervisor May We contact this Employer? Yes No Phone Employment dates: From DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM 1 2 3 4 5 6 7 8 9 10 11 12 YYYY 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Employment dates: To DD 12 3456789101112131415161718192021222324252627282930 31 MM 12 34 56 78 910 1112 YYYY 2025 20242023 20222021 20202019 20182017 201620152014201320122011 20102009200820072006 20052004200320022001 20001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921 1920 Reason For Leaving If No, please explain why: Employment Two Employment History Company, Agency name Address Job title Weekly Pay Supervisor May We contact this Employer? Yes No Phone Employment dates: From DD 1 2 345678910111213141516171819202122232425262728293031 MM 12 34567891011 12 YYYY 20252024 20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Employment dates: To DD 12345678910111213141516171819202122232425262728293031 MM 123456789101112 YYYY20252024 20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Reason For Leaving If No, please explain why: Employment Three Employment History Company, Agency name Address Job title Weekly Pay Supervisor May We contact this Employer? Yes No Phone Employment dates: From DD 12 3456789101112131415161718192021222324252627282930 31 MM 1234567891011 12 YYYY 2025 202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Employment dates: To DD 12345678910111213141516171819202122232425262728293031 MM 123456789101112 YYYY 202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921 1920 Reason For Leaving If No, please explain why: Previous Next Layout Did you serve in the US Armed Forces? * Yes No If yes, in which branch? Describe any military training you received that you believe would be pertinent to the position for which you are applying. Previous Next Layout Reference Name * Reference Name * Reference Name * Reference Telephone: * Reference Telephone: * Reference Telephone: * EQUAL OPPORTUNITY EMPLOYER Access Safe Care, LLC is an equal opportunity employer and is committed to providing equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, age, national origin, mental and physical disability, veteran or family status, genetic information, or any other status or condition protected by applicable federal, state, or local laws, except where a bona fide occupational qualification applies. BACKGROUND CHECK INFORMATION Access Safe Care, LLC (ASC) conducts background checks on all employees to ensure the safety and well-being of our clients and maintain a secure working environment. Background information is obtained from relevant authorities, including but not limited to the State Bureau of Investigation, the Department of Health & Human Services, and the Bureau of Motor Vehicles. If an applicant has resided in states other than our primary location, ASC reserves the right to conduct appropriate out-of-state background checks. Applicants acknowledge that any information revealed in these checks that pertains to incidents in their past, affecting their ability to work with consumers/clients, staff, or the operation of the program, may be grounds for rejecting the application or immediate termination if already employed. I, the undersigned applicant, affirm that the information provided in this application for employment is true, correct, and complete. I understand that providing false, incomplete, omitted, or misrepresented information may result in the rejection of my application or termination if discovered after employment. I authorize ASC to contact and obtain information from previous employers, educational institutions, and references I have provided, as well as any other party necessary to verify the accuracy of the information disclosed in this application or related documents. This application is not an employment agreement. If I accept an offer of employment from ASC, I understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with ASC is of an "at-will" nature. My employment is at the will of the employer, and either ASC or I may terminate the employment relationship at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than the managing director of the agency, has the authority to enter into any employment agreement with terms contrary to the foregoing, and then only in writing signed by the managing director. I fully understand and accept all terms and conditions of the above statement. 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