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EDUCATION


LICENSE / CERTIFICATIONS / EXAMINATIONS
GENERAL INFORMATION

If you become an employee of this Agency you will be required to provide documentation proving your eligibility to work in the USA

This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.

In case of emergency, notify

WORK HISTORY

Employment Dates

Compensation


Employment Dates

Compensation


Employment Dates

Compensation


Employment Dates

Compensation

In accordance with Title VI of the Civil Rights Act of 1964 and its implementing regulation, Angels Care Home Health Service, LLC is an EQUAL OPPORTUNITY EMPLOYER and WILL NOT DISCRIMINATE AGAINST RACE, COLOR, SEX, CREED, NATIONAL ORIGIN OR COMMUNICABLE DISEASE AS DEFINED IN SECTION 504 OF TITLE VI. In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation Angels Care Home Health Service, LLC WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF HANDICAP. In accordance with the Age Discrimination Act of 1975 and its implementing regulation Angels Care Home Health Service, LLC WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF AGE in the provision of services, unless age is a factor necessary to the normal operation or the achievement of any statutory objective. In accordance with the Americans with Disabilities Act of 1992 (42 USC §12101) and its implementing regulations, (private employers with more than 25 agency personnel), Angels Care Home Health Service, LLC WILL NOT DIRECTLY OR THROUGH CONTRACTUAL OR OTHER ARRANGEMENTS, DISCRIMINATE ON THE BASIS OF DISABILITY. A disability is a physical or mental impairment that substantially limits a major life activity, or for which there is a record of impairment or which causes the individual to be regarded as impaired.

The information that I have given is true and accurate to the best of my knowledge

ADDENDUM TO EMPLOYMENT

The Ohio Administrative Code (5123:2-.05) requires that home health companies ascertain from applicants for employment that have not been convicted or plead guilty to the offenses listed below. Your signature below indicates that you have not committed nor plead guilty of:

Aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, failing to provide for a functionally impaired person, aggravated menacing, patient abuse and neglect, kidnapping, abducting, criminal child enticement, rape, sexual battery, unlawful sexual conduct, with a minor, gross sexual imposition, importuning, voyeurism, public indecency, compelling prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually oriented materials involving a minor, illegal use of a minor in nudity-oriented material or performance, aggravated robbery, robbery, aggravated burglary, burglary, unlawful abortion, endangering children, contributing to the unruliness or delinquency of a child, domestic violence, carrying a concealed weapon, having weapons while under disability, improperly discharging a fire arm at or into a habitation of school, corrupting others with drugs, trafficking in drugs, illegal manufacture of drugs or cultivation of marijuana, funding of drugs or marijuana trafficking, illegal administration or distribution of anabolic steroids, placing harmful objects in food or confection, child stealing, possession of drugs, felonious sexual penetration.

I have read the contents of this addendum to my application for employment with Angels Care Home Health Service, LLC. I also understand that I am required by law to notify Angels Care Home Health Service, LLC, within 14 (fourteen) days if I receive formal charges, convictions, or make a guilty plea to any one of the disqualifying offenses listed above.

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