EmailMe Form - Smart Choice Home Healthcare Application

Name *

First Last

DOB (Format 03/19/1975) *

Social Security Number *

Email *

Cell Phone *

### - ### - ####

Home Phone

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Attach 2 Forms of ID
(May take clear picture of IDs together and attach) *

Are you a citizen of the United States? *

Yes

No

No, but I am authorized to work in U.S.

Are you at least 18 or older? *

Yes

No

Do you have a Driver's License?

Yes

No

Do have reliable transportation?

Yes

No

What license do you currently hold? *

HHA/STNA/CNA

RN

LPN

None

Position applying for and desired hourly wage?

HHA $14 Per Hour
CNA $15 Per Hour
DSP $15 Per Hour
STNA $16 Per Hour
LPN $25-$28 Per Visit
RN $30-$35 Per Visit *

Attach HHA/CNA Certificate

Are you a high school graduate? *

Yes

No

Currently in school to obtain my HS diploma and will be complete within 2 years or less

I have my GED

Attach HS Diploma or GED

Have you ever been convicted of a felony? If so, describe below *

Yes

No

Attestation and Agreement to Notify Employer

I hereby attest that I have not been convicted of or pleaded guilty to any of the disqualifying offenses listed below
and agree that I will notify Smart Choice Home Healthcare Services, LLC within 14 calendar days, if while employed I am formally charged with, am convicted of, or plead guilty to one of the disqualifying offenses. I understand that failure to make this notification may result in termination of employment.

(Your typed name serves as your signature that you agree to this attestation and agreement to notify employer)

Name and Date *

Tier 1 Disqualifying Offenses (Permanent Exclusion):
2903.01 (aggravated murder)
2903.02 (murder)
2903.03 (voluntary manslaughter)
2903.11 (felonious assault)
2903.15 (permitting child abuse)
2903.16 (failing to provide for a functionally impaired person)
2903.34 (patient abuse and neglect)
2903.341 (patient endangerment)
2905.01 (kidnapping)
2905.02 (abduction)
2905.32 (human trafficking)
2905.33 (unlawful conduct with respect to documents)
2907.02 (rape)
2907.03 (sexual battery)
2907.04 (unlawful sexual conduct with a minor, formerly corruption of a minor)
2907.05 (gross sexual imposition)
2907.06 (sexual imposition)
2907.07 (importuning)
2907.08 (voyeurism)
2907.12 (felonious sexual penetration)
2907.31 (disseminating matter harmful to juveniles)
2907.32 (pandering obscenity)
2907.321 (pandering obscenity involving a minor)
2907.322 (pandering sexually oriented matter involving a minor)
2907.323 (illegal use of minor in nudity-oriented material or performance)
2909.22 (soliciting/providing support for act of terrorism)
2909.23 (making terrorist threat)
2909.24 (terrorism)
2913.40 (Medicaid fraud)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
A conviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the Revised Code (illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits).
A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 2 Disqualifying Offenses (Ten-Year Exclusion):
2903.04 (involuntary manslaughter)
2903.041 (reckless homicide)
2905.04 (child stealing) as it existed prior to July 1, 1996
2905.05 (criminal child enticement)
2905.11 (extortion)
2907.21 (compelling prostitution)
2907.22 (promoting prostitution)
2907.23 (enticement or solicitation to patronize a prostitute, procurement of a prostitute for another)
2909.02 (aggravated arson)
2909.03 (arson)
2911.01 (aggravated robbery)
2911.11 (aggravated burglary)
2913.46 (illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits)
2913.48 (workers' compensation fraud)
2913.49 (identity fraud)
2917.02 (aggravated riot)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2923.12 (carrying concealed weapon)
2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordnance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone)
2923.123 (illegal conveyance, possession, or control of deadly weapon or dangerous ordnance into courthouse)
2923.13 (having weapons while under disability)
2923.161 (improperly discharging a firearm at or into a habitation or school)
2923.162 (discharge of firearm on or near prohibited premises)
2923.21 (improperly furnishing firearms to minor)
2923.32 (engaging in pattern of corrupt activity)
2923.42 (participating in criminal gang)
2925.02 (corrupting another with drugs)
2925.03 (trafficking in drugs)
2925.04 (illegal manufacture of drugs or cultivation of marihuana)
2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs)
3716.11 (placing harmful objects in food or confection)
A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.
Rule 5123:2-2-02 (effective January 1, 2013)

Tier 3 Disqualifying Offenses (7-Year Exclusion):
959.13 (cruelty to animals)
959.131 (prohibitions concerning companion animals)
2903.12 (aggravated assault)
2903.21 (aggravated menacing)
2903.211 (menacing by stalking)
2905.12 (coercion)
2909.04 (disrupting public services)
2911.02 (robbery)
2911.12 (burglary)
2913.47 (insurance fraud)
2917.01 (inciting to violence)
2917.03 (riot)
2917.31 (inducing panic)
2919.22 (endangering children)
2919.25 (domestic violence)
2921.03 (intimidation)
2921.11 (perjury)
2921.13 (falsification, falsification in theft offense, falsification to purchase firearm, or falsification to obtain a concealed handgun
license)
2921.34 (escape)
2921.35 (aiding escape or resistance to lawful authority)
2921.36 (illegal conveyance of weapons, drugs, or other prohibited items onto grounds of detention facility or institution)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2925.05 (funding of drug or marihuana trafficking)
2925.06 (illegal administration or distribution of anabolic steroids)
2925.24 (tampering with drugs)
2927.12 (ethnic intimidation)
A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier 4 Disqualifying Offenses (Five-Year Exclusion):
2903.13 (assault)
2903.22 (menacing)
2907.09 (public indecency)
2907.24 (soliciting after positive human immunodeficiency virus test)
2907.25 (prostitution)
2907.33 (deception to obtain matter harmful to juveniles)
2911.13 (breaking and entering)
2913.02 (theft)
2913.03 (unauthorized use of a vehicle)
2913.04 (unauthorized use of property, computer, cable, or telecommunication property)
2913.05 (telecommunications fraud)
Tier 4 Continued
2913.11 (passing bad checks)
2913.21 (misuse of credit cards)
2913.31 (forgery, forging identification cards)
2913.32 (criminal simulation)
2913.41 (defrauding a rental agency or hostelry)
2913.42 (tampering with records)
2913.43 (securing writings by deception)
2913.44 (personating an officer)
2913.441 (unlawful display of law enforcement emblem)
2913.45 (defrauding creditors)
2913.51 (receiving stolen property)
2919.12 (unlawful abortion)
2919.121 (unlawful abortion upon minor)
2919.123 (unlawful distribution of an abortion-inducing drug)
2919.23 (interference with custody)
2919.24 (contributing to unruliness or delinquency of child)
2921.12 (tampering with evidence)
2921.21 (compounding a crime)
2921.24 (disclosure of confidential information)
2921.32 (obstructing justice)
2921.321 (assaulting/harassing police dog or horse/service animal)
2921.51 (impersonation of peace officer)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using any dangerous veterinary drug)
2925.11 (drug possession other than a minor drug possession offense)
2925.13 (permitting drug abuse)
2925.22 (deception to obtain dangerous drugs)
2925.23 (illegal processing of drug documents)
2925.36 (illegal dispensing of drug samples)
2925.55 (unlawful purchase of pseudoephedrine product)
2925.56 (unlawful sale of pseudoephedrine product)
A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

Tier five: no exclusion
2925.11 (drug possession that is minor drug offense);
2925.14 (illegal use or possession of drug paraphernalia);
2925.141 (illegal use or possession of marihuana drug paraphernalia); or
A violation of an existing or former municipal ordinance or law of any state, or the US that is substantially equal to the offenses or violations 2925.11, 2925.14 or 2925.141.
Rule 5123:2-2-02 (effective January 1, 2013) *

No, I have not been convicted of any disqualifying offense listed above

Yes, I have been convicted of at least 1 offense and/or at least 1 exclusion listed above

Describe your felony/offense along with year/date of conviction:

Have you been in Ohio the past 5 years? *

Yes, (BCI is required)

No, (BCI & FBI is required)

What shifts would you prefer?

Current Employer COMPANY Name and Phone number (Company Name Only No Personal Reference DO NOT PUT N/A IF YOU PUT N/A YOU WILL NOT BE CALLED FOR A POSITION) *

Dates of Employment *

May we contact this employer for reference check *

Yes, I am providing written consent

No

Describe Experience

Previous Employer COMPANY Name and Phone number (Company Name Only No Personal Reference DO NOT PUT N/A IF YOU PUT N/A YOU WILL NOT BE CALLED FOR A POSITION) *

Dates of Employment *

Reason for leaving *

Previous Employer COMPANY Name and Phone number (Company Name Only No Personal Reference DO NOT PUT N/A IF YOU PUT N/A YOU WILL NOT BE CALLED FOR A POSITION) *

Professional/Employment Reference and Phone Number *

May we contact your professional/employment references? Please note if you answer yes, you are providing Smart Choice written consent to contact your references *

No

Yes, I am providing written consent

Military Service
Branch:
From:
To:

Rank at Discharge:
Type of Discharge:

If other than honorable, explain:

How did you hear about us? *

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.

(Your typed name serves as your signature that you agree to the answers are true and complete to the best of your knowledge)

Name & Date *