Employee Application Form template designed for prospective caregivers and other staff members, created for agencies in the healthcare and Medicaid waiver space. This comprehensive form covers all essential sections needed to assess qualifications and ensure compliance with healthcare standards.

Employee Application Form

1. Personal Information

• Full Name: _____________________________________________
• Date of Birth: ___________________________________________
• Social Security Number: __________________________________
• Current Address:
  • Street Address: _______________________________________
  • City, State, Zip Code: __________________________________
• Phone Number: _________________________________________
• Email Address: __________________________________________
• Emergency Contact:
  • Name: _____________________________________________
  • Relationship: ________________________________________
  • Phone Number: ______________________________________

2. Position Information

• Position Applied For: ____________________________________
• Date Available to Start: ___________________________________
• Desired Salary: _________________________________________
• Employment Type: ( ) Full-Time ( ) Part-Time ( ) PRN ( ) Temporary

3. Employment Eligibility

• Are you legally authorized to work in the United States? ( ) Yes ( ) No
• Will you now or in the future require sponsorship for employment visa status? ( ) Yes ( ) No

4. Employment History

(Please provide employment history for the last five years, starting with the most recent job)

Employer #1

• Employer Name: _____________________________________
• Position Held: _______________________________________
• Employment Dates (MM/YYYY): From _________ to ________
• Supervisor’s Name and Title: __________________________
• Supervisor’s Phone Number: __________________________
• Reason for Leaving: _________________________________

Employer #2

• Employer Name: ____________________________________
• Position Held: ______________________________________
• Employment Dates (MM/YYYY): From ____________ to ____
• Supervisor’s Name and Title: _________________________
• Supervisor’s Phone Number: _________________________
• Reason for Leaving: _________________________________

5. Education & Training

• High School: _______________________________________
  • Diploma or Equivalent: ( ) Yes ( ) No
• College/University: __________________________________
  • Degree Received: ________________________________
• Vocational or Additional Training: _____________________
  • Certification Received: ____________________________

6. Licensure & Certification

• License/Certification Type: ____________________________
• License Number: ____________________________________
• Issuing State: _______________________________________
• Expiration Date: _____________________________________
• Additional Certifications (e.g., CPR, First Aid): ___________

7. Background Information

• Have you ever been convicted of a felony? ( ) Yes ( ) No
  • If yes, please explain: __________________________________
• Have you ever had your professional license or certification revoked? ( ) Yes ( ) No
  • If yes, please explain: __________________________________
• Are you able to pass a background check required by state regulations? ( ) Yes ( ) No

8. Health and Physical Requirements

• Are you physically able to perform the essential duties of the position for which you are applying, with or without reasonable accommodation? ( ) Yes ( ) No
• Do you have any health-related restrictions or conditions that would impact your work performance? ( ) Yes ( ) No
  • If yes, please describe: __________________________________

9. Skills and Qualifications

• Relevant Skills or Specializations: __________________________
• Languages Spoken (besides English): _______________________
• Additional Training Completed: ____________________________

10. References

(Please provide three professional references, excluding relatives)

Reference #1

• Name: __________________________________________
• Relationship: ____________________________________
• Phone Number: ___________________________________

Reference #2

• Name: __________________________________________
• Relationship: ____________________________________
• Phone Number: ___________________________________

Reference #3

• Name: __________________________________________
• Relationship: ____________________________________
• Phone Number: ___________________________________

11. Applicant’s Statement

I certify that all information provided in this application is true and complete. I understand that false or misleading information provided in my application may result in disqualification from employment or dismissal if employed.

• Signature of Applicant: ______________________________________
• Date: _____________________________________________________

Thank you for applying!

You may reach out to us for a more customized form based on your state-specific regulation. Call 302.888.9172 or email licensing@waivergroup.com for assistance. To learn more about essential policy and procedural guidelines, visit our Policy and Procedures page. Explore our consulting services at Waiver Consulting Group for expert support in achieving and maintaining compliance for healthcare and Medicaid waiver agencies.