Apply Now

Employment Checklist & Requirements

Thank you for your interest in joining our team at FIVE STAR COMPANION CARE, (hereinafter “Agency”), and to ensure compliance with staff regulations set forth by the Pennsylvania Department of Health and Federal Law, the following is a list of documentation that must be provided, completed and or turned in by each individual applying for employment at our Agency.


  1. Employment Application signed and completed (references checked: required)
  2. Copy of High School Diploma or higher
  3. OPTIONAL: Resume
  4. Social Security Card
  5. Driver’s License or State issued I.D.
  6. Criminal Background Check (through P.A.T.C.H)
  7. OPTIONAL: Current CPR Certification
  8. Completed W-4
  9. Completed I-9 Form (Employment Eligibility Verification Form)



  1. Has the employee gone through the Agency’s Training Orientation Program (TOPS) and passed the Competency Test (§ 611.55)?
  2. Has a TB screening been done by the Employee (any direct care workers, contractors and office staff with direct consumer contact)?
  3. Does the Employee have a Photo ID Badge?
  4. Has the Employee received, reviewed and signed the Agency’s Handbook?
  5. Does the Employee have an Agency issued uniform?
  6. Has the Employee reviewed the Patient’s Intake Form with the Supervisor?
  7. Can the Employee perform all the Patient requested services on in-take form?
  8. Has the employee reviewed the Patient’s Emergency Plan?
  9. Does the Employee know where the Agency forms are located in the Patients home?
  10. Does the employee have adequate transportation to and from the Patient’s home?
  11. Did the Agency owner introduce the Patient and Employee at the Patient’s home?

As a licensed Home Care Agency in the state of Pennsylvania, we are required and mandated by the Pennsylvania Department of Health to maintain photocopies of the aforementioned documents on file at our office for all full-time, part-time and intermittent employees and contractors. This Agency does take security of your information very seriously. Please be assured that all information provided to us will be kept private, safe and confidential and would be divulged only when mandated by the law or government regulations.

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.

Apply Now


Current Address
Previous Address
Emergency Contact Name
Emergency Contact Name
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?


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:


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?



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

Please Check Your Highest Completed Grade:


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?


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?


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.

Proudly Serving The Following Counties In Pennsylvania

Philadelphia                    Montgomery                    Delaware                    Chester                    Bucks