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Now Hiring Caregivers

What You Need to Get Started

Employment Application

✔ Completed Employment Application
☐ In Person (call to schedule)
☐ Online: www.fivestarcompanioncare.com

TB Testing Requirements (Must be current - within 1 year)

Option 1: 2-Step PPD Test
• Step 1: PPD placed under skin (forearm)
Return in 48–72 hours for reading
• Step 2: Second test given 1–3 weeks later
Return again in 48–72 hours
✔ Both steps must be completed

Option 2: QuantiFERON®-TB Gold Blood Test
• Blood draw from arm
• Lab testing for TB exposure
• Faster results
• No injections
• No return visit required

Background Check Requirements (Must be current - within 1 year)

  • Criminal Background Check
  • Website: www.epatch.pa.gov (Submit under Employment)
    • Agency can complete for you
    • Fee: $25 (Cash or Money Order) Payable to: Five Star Companion Care

Reference Requirements

  • Three (3) references required
  • No relatives
  • Please notify your references in advance

Orientation Requirement

  • Completion of Agency Orientation is required prior to starting work
  • No caregiver may provide services before orientation is completed and approved

Document Submission

Submit required documents to:
info@fsccagency.com

Or drop off at the office
(By appointment only)

Questions or Concerns?

267-297-7395

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FSCC Employment Application

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your need in a reasonable amount of time.

  • Please read “Applicant Note” below.
  • Complete all pages of this application.
  • Print Clearly. Incomplete or illegible applications may not be accepted.
  • If more space is needed to complete any question, use the comments section on the back.
  • Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with our Home Care Agency. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

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PERSONAL INFORMATION

First
Last
Current Address
City
State/Province
Zip/Postal
Country
Previous Address
City
State/Province
Zip/Postal
Country
Emergency Contact Name
Emergency Contact Name
First
Last
Have You Ever Submitted An Application Here?
Have You Ever Been Employed Here Before?
Have You Been Given A Copy Of The Job Description You Are Applying For?
Are You Able To Perform The Essential Functions Of The Job For Which You Are Applying With Or Without A Reasonable Accomodation?

YOUR AVAILABILITY

Due to the nature of the business, no guarantee can be made as to the schedule or amount of hours worked.

Please Check All Areas Of Availability:

Please indicate the hours you are available to work each day:

PREFERENCES

Please Indicate All Areas Of The City/County In Which You Are Willing To Work:
Please Indicate The Types Of Services You Are Willing To Provide:
Are You Willing To Provide Service To A Client With A Pet?
If Yes, Which Ones?
Are You Willing To Provide Service To A Client Who Smokes?
Do You Have Any Experience With Alzheimer's?
Do You Have Any Experience With Operating A Hoyer Lift?

JOB RELATED SKILLS

EDUCATION

For employment our minimum education requirement is either a GED or High School Diploma.

Please Check Your Highest Completed Grade:

WORK HISTORY

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Are You Currently Working For This Employer?
If Yes, May We Contact?

SECURITY

As A Condition Of Employment, All Employees Must Be "Bondable & Insurable." Are You At Least 19 Years Of Age?
Have You Had Any Moving Traffic Violations?

REFERENCES

Please complete all three (3) references. Your application will not be considered unless three (3) references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all three (3) references, you will be asked to provide additional references. Do not include relatives.

Applicant Notice

It is illegal in Philadelphia for employers to ask about your criminal background during the job application process.

Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depends on the results of your background check.

  • Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting time of incarceration)
  • Arrests that did not lead to conviction cannot be used in any employment decisions.
  • If your background check reveals a conviction, the employer must consider:

The type of offense and the time that has passed since it occurred.

Its connection to the job you are applying for; and

  • Your job history, character references, and any evidence of rehabilitation
  • Employers can reject you based on your criminal record ONLY if you pose an unacceptable risk to the business or to other people.
  • If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision.
  • You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.

Applicant Certification & Release

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.

I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the Company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations.

I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug

Testing to detect the use of illegal drugs prior to and during employment, I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of a drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and Myself is terminable at-will, so that both the company and I remain free to choose to end our work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

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