Application Form

PERSONAL REFERENCES

(Please provide two personal references that are not family members)

PREVIOUS EMPLOYMENT

(Must give two previous employment histories)

DISCLAIMER

Applicant understands that this is an Equal Opportunity Registry and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed for it to be considered.

Please complete each section

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual placement as an independent Contractor for True Vine Home Care, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

Dear Independent Contractor:
In joining TRUE VINE HOME CARE, you are agreeing for this registry to act as your agent, in providing you with work opportunities in home health care. You are referred to clients as an INDEPENDENT CONTRACTOR; therefore, you suffer any profit, loss risk and benefits. TRUE VINE HOME CARE does not provide W2’s, as you are not an employee. You are as an independent contractor, responsible for your own Federal and State taxes. TRUE VINE HOME CARE does not provide insurance, including but not limited to; workman’s compensation, liability insurance or unemployment benefits. In addition, some clients may request a contractor’s social security number for tax purposes.

Give TRUE VINE HOME CARE permission to ONLY provide my social security number to clients that I have furnished services to upon their request to file a 1099 Form for tax purposes.

I have fully read and understand the statements on this page

Applicant fill out top portion ONLY

You have my permission to provide my reference to the agency above.

The above applicant has applied for a position and TRUE VINE HOME CARE. He/She has provided this name as an employment reference. Please confirm dates of employment and any additional comments on this applicant at your earliest convenience. Thank you for your assistance in this matter.

Regards,
Tanya Billstone, Owner

BACKGROUND CHECK INFORMATION

The information requested below is collected solely for the purpose of aiding the Company in running a background check in connection with your application for employment. The employer is requesting that you provide this information to assist in conducting a thorough background check.

For residents of, or for jobs located in Utah, please do NOT provide your date of birth, social security number or driver’s license number until instructed to do so by the Company.

In connection with my application for employment (including contract or volunteer services) with TRUE VINE HOME CARE, (“Company”) I understand consumer reports and/or investigative consumer reports will be requested by Company and its Agency. These reports may contain information about your character, general reputation, personal characteristics and mode of living. These reports may include, but are not limited to, credit reports and credit history information; criminal, civil and other public records and history; public court records (e.g., bankruptcies, tax liens and judgements); motor vehicle and driving records; educational and employment history, including professional disciplinary actions; drug/alcohol test results; and social security verification and address history, subject to any limitations imposed by applicable federal and state law. This information may be obtained from public record and private sources, including credit bureaus, government agencies and judicial records, former employers and educational institutions, and other sources.

I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights by signing this form.

In connection with my application for employment (including contract or volunteer services) with TRUE VINE HOME CARE (“Company”) I understand investigative consumer reports may also be obtained by Company and its Agency. These reports may include information gathered from personal interviews, as applicable, with former employers, past or current associates of mine, etc., to gather information regarding my work, character, general reputation, mode of living and personal characteristics, and professional or educational qualifications may be obtained. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights by signing this form.

I hereby authorize procurement of consumer and investigative report(s) by TRUE VINE HOME CARE (“Company”) from Agency. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Company to procure such reports at any time during my employment, contract, or volunteer period. I authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the above-mentioned information.

This authorization is conditioned upon the following representations of my rights:

I understand that I have the right to make a request to the consumer reporting agency: B&B Reporting, (“Agency”), 401 South Market Street, Scottsboro, Alabama 35768, telephone number (256) 574-2524, (toll free telephone number) 844-752-1356, upon proper identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and the Agency, on Company’s behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two-year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to Company obtaining the above information from the Agency. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website: www.bbreporting.com.

I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of Rights by signing this form.

I authorize Company and Agency and my employer to use email communication with me to provide me with notices and information regarding any report or use of such report. The background check Disclosure and Authorization forms, in original, faxed, photocopied, or electronic form, will be valid for any reports that may be requested by Company or Agency.