Employment Application

Applicant Information

Social Security Number (Full)

Emergency Contact Name

Emergency Contact Phone

Are you a U.S. Citizen?

Yes No

If no, are you legally authorized to work in the U.S.?

Have you ever been employed by this company before?

Yes No

If yes, provide position and dates

Have you ever been convicted of a felony?

Yes No

Position & Availability

Position Applying For

Date Available to Start

Preferred Employment Type

Do you have reliable transportation?

Yes No

Are you willing to work weekends and holidays if required?

Yes No

Employment History

List your last three (3) employers beginning with the most recent.

Dates of Employment:

May we contact this employer?

Yes No

Dates of Employment:

May we contact this employer?

Yes No

Dates of Employment:

May we contact this employer?

Yes No

Education & Training

Additional Training/Certifications

Professional Licenses (CNA, LPN, RN, CPR, etc.)

Professional References

List three professional references who can verify your qualifications (no family members).

May we contact this reference?

Yes No

May we contact this reference?

Yes No

May we contact this reference?

Yes No

Background Check & Exclusion Policy

In compliance with Indiana Code § 16-27-2 and House Enrolled Act 1457 (effective July 1, 2025), A Passionate Helping Hand Home Health Care LLC is required to conduct comprehensive criminal background checks on all employees.

A background check must be initiated within three (3) business days of employment start.
If the applicant lived outside Indiana in the past 2 years, an Expanded Lifetime Criminal History Check is required.
Disqualifying convictions include rape, criminal deviate conduct, exploitation or neglect of an endangered adult, and theft within the last ten (10) years.
Lifetime exclusion applies to violent and exploitation crimes; theft convictions carry a 10-year exclusion.
Grandfathering: convictions permitted before July 1, 2025 only remain valid with the current employer; moving to a new employer triggers new disqualification rules.
Vendors such as Indiana State Police or Safe Hiring Solutions may be used.
For questions, contact IDOH: aideinvestigations@health.in.gov.

Acknowledgment & Certification

I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that false, incomplete, or misleading information may disqualify me from employment or result in termination. I authorize the verification of the information provided, including references and criminal background checks, as required by law.

I understand that employment with A Passionate Helping Hand LLC / A Passionate Helping Hand Home Health Care LLC is at-will and may be terminated at any time, with or without cause or notice, in accordance with applicable laws.

Signature of Applicant:

A Passionate Helping Hand LLC A Passionate Helping Hand Home Health Care LLC

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Applicant Information

Position & Availability

Employment History

Education & Training

Professional References

Background Check & Exclusion Policy

Acknowledgment & Certification

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