Field staff will be asked to upload a current auto insurance card on the Documents page. Independent contractors will also upload proof of professional liability insurance.

List your most recent employers. You may upload a resume on the Documents page, but please complete at least one employer here for Medicare/Medicaid compliance.

Have you ever been convicted of a crime (other than minor traffic violations), pled guilty or no contest, or had a deferred judgment?

No Yes

A conviction does not automatically disqualify you. Factors such as the nature of the offense, time elapsed, and relationship to the job will be considered in accordance with applicable law.

By submitting this application, I understand and agree that:

The information I have provided is true and complete to the best of my knowledge.
Any misrepresentation or omission may disqualify me from employment, or if hired, may result in immediate termination.
Saintly Home Health LLC may verify information in this application, including employment history, licensure, references, criminal background, OIG/Medicaid exclusion status, and other screenings as required by law, Medicare/Medicaid, and CHAP.
If hired as an employee, my employment is “at will” and may be terminated at any time, with or without cause and with or without notice, subject to applicable law.

I certify that the information in this application is true and complete. I authorize Saintly Home Health LLC to conduct background and exclusion checks consistent with applicable laws and regulations.

Electronic Signature (type full legal name)

Date

Saintly Employment Application

Saintly Home Health LLC

Employment Application