ffiS,Servicesandemp1oymentisavai1ab1etoa11PerSonS.ThoseappIicantsrequiringreasonableaccommodation to the application and/or irrt..ui.* pr"..., ,rr""16 ,rotis, a representalive of the Human Resources Department'

Applicant ID #

Name First

I wutt -i

Address

TtrnT

CityStreet/\

Telephone # l. / Cellular/OtherPhone#( ) E-mailAddress

check the appropriate category and list the source')

I school

E lob rui.

E Staffing AgencY

I GovernmentEmploYment AgencY

E oth..

Will you work overtime if required? ""'

Date of aPPlicationPosition(s) aPPlied for

Referral Source (Ptease

Employee

Advertisement

Other Internet

Company's Website

A14

PMf Yes trNo

Ifnecessary, best time to call you is ."""""""""'E Ho*. I Cellular/Other Ifno, please exPlain

EY.s ExoMay we contact You at work?

If yes, work number and best time to cail:

Ifyou are under 18 and it is required,

can you furnish a work permit?""""""

PT4 Are you able to perform the "essential functions" ofthe job

fo, *f,i.h you ui. applpng (with or without reasonable

accommodation)?

lhisquestio:l'lsnotdesignedls*iicitinfc'rrnationai:*niallepFli{$nl'sriis*iriiittr'';1;;;" nci provide iriurnatirn a5o$t the edster:ce of a c?sabil.itii sa*lcular

accorT:rilodaiion, or whether aceernmodation 'is mecessanl" Un*n* 'uuu"u

*"t "o

adciressed at a later staqie to the *xteni permitted L]y iaw'

xye. rxo ril"r.q.*"#JlifrffiL"J,,1r;:#*

Driver's license number required if driving may be required in the

job for which You are aPPlYing:

Iv.r ENo

Ifno, please exPlain:

Have you submitted an application here before?......f]Y.t IxoIfyes, give date(s) and position(s):

Have you ever been employed here before? ' E ytt I Xo

Ifyes, give dates: From / / l' / /State

Is this application a request for reemployment

following an extended military leave of absence

from this comPanY?..... E Ytt I No

If yes, additional information maybe requested'

Are you 1ega1ly eiigible for employment

in this country?.'....'...'...'.'.. [l yts E No

Date available for work....

What is your desired salary range or hourly rate of pay?

" Pet'''''-.-.......-'.-......'-''.....---'-''-

Type of employment desired: E pt'l1-Ti-e E Part-Time

E Educationai Co-Op E Seasonal E Te*po'uty

Will you relocate if job requires it? """""""" E yts E No

Will you travel if job requires it? ..""""""""' """""""tr Yes E No

If they have been explained to you, are you able to meet the

attendance requirements of the position? "' E Ni A E Yes E No

Haveyoueverbeenbonded? EYes ENo

:\nslvering "yes"'tE tiie fo!.t*w1ng question d$es rxsl a*i!'titu!* fir! aut$$:iti' i:'41't*

-*pi-y*i"*. Factsrs such as daie'cf the offense' seriousness *llri naiure of ilie

U*L*ion, rehabiiitation ai:d p*lit'ion a;:rp[ied far urii[ ile taken i:]to 'rc'*L!rit"

Have you ever pleaded'guilry" or "no contest" to

;';;#;";;iJorucrime?...'..'..'.' """Ives IisoIfyes, please provide date(s) and details:

Have you entered into an agreement with any former employer or

other party (such as a noncompetition agreement) that might' in any

*uy, ,.u.io your ability to *o.k fo. ouriompany?"""" E yet E No

Ari reui{L Srp*ftT{-lN?rY E}4PLsYEft Fage 1

Starting with Your most recent employer provide the following information

EmployerTelephone f

street addressCjty

Starting job titte/finatjob titie

I*.di.t".rp.ruitot and title (for most recent position held)

Why did you leave?

ffi*i^ th. typu of work performed and job responsibi[ties'

Dates emptoyed

Commission/Bonus/0ther Compensation

!$

t$

Commission/Bonus/0ther Compensation

What did you [jke most about your position?

What were the things you [iked teast about the posjtion?

EmpLoyer

Street address

Starting job title/final job tjtle

I*.di.tu rrp.tito, and title (for most recent posjtion hetd)

Why did you leave?

Summarize the type of work performed and job responsibilities'

Dates employed:

Commission/Bonus/0ther Compensation

Comm jssion/Bonus/other Compensation

!$

What did you like most about your position?

What were the things you tiked least about the positjon?

Emptoyer

Street address

Starting job tjtte/finai job title

Imediate supervisor and title (for most recent position heLd)

WhV did you teavel

Dates emploved:

Commission/Bonus/0ther Compensation

Commission/Bonus/0ther Compensation

q

$

T

$

Summarjze the type of work performed and job responsibilities'

What did you like most aboui your positjon?

What were the thi.gs you iiked least about the position?

Em ptoyer

Street address

Stadjng job titLe/finaljob title

Why did you ieave?

Tetephone IDates employed:

Commission/Bonus/other Iompensation

I$

Immediate supervisor and tjtle (for most recent position held)

Summarize the type of work performed and j0b responsibitities'

What were the thinqs you tiked ieast about the position?

Page 2

Commissjon/Bonus/0ther Compensation

What did you like most about your position?

Explain any gaps in your employment, other than those due to personal illness' injury or disability'

Ive. IxoIfnot addressed on Previous Page, have you ever been fired or asked to resign from a job?""""""'

Ifyes, please exPlain:

ficatesthatmayassistyouinperformingthepositionforwhichyouareapp1ying:

Computer Skills (Check appropriate boxes' Inctude software tittes and years of experience.)

E InternetI Word Processing Years:

Years:

Years:

Years:

[-l Soreadsheet

DE-mail

E Presentation

I other

E Other

D Other

Years:

Years:

Years:

Years:

school attended, the following information.

List names and telePhone

Ifnot applicable, list threenumbers of three business/work references who are

school or personal references who are notrelatedtonot re\ated to you and are not previous supervlsors'

you.

SS#

only for employment purposes and make reasonable

Page 3

We will use this information efforts to safeguard your privacy.

To what job-related organizations

Exclude n'rernbershiS:s that wcutd revear'

veteranfir:serue, llati*nal iiuard err any

(professional, trade, etc.) do You belong?inforn'l*ticrn" eitiz*rrship' a9e, nres:ti:l rrr phl,sir:aL riisabiijties'

rac*, sol'oi'" r*r"igi*n, sex,

*tirer sirn'ilartY Prot*eted

r;ationat origin, geri*tie

status.

List special accompiishments' publications' awards' etc'

Excturi* iE:f*r.rnatisn thet r",",autd. reveat *:;=, ,YiT;,:--i:y::":;:r-$]fl:1 *rlgin

ii#;;l;;;;,ve,-i*ati*na[ Guard or anv ckl'rer simitartv rro,'*ated status'

genetic ii:forrnati*n, citlz*nsi:lp, a**' i:lental r'r ohysis;ai disai:iiiti*s'

you ever written instructions or directions to be followed by employees or customers?

In your current or a previous job' have

I Yes n Xo I Xot APPiicable

Ifyes, please exPlain:

Is there any other job-related information you want us to know about you?

I certi8/ that all information I have provided in order to apply for and secure work with this emP]oyer iS tlue, complete and correct.

non-defamatorY information, in

from consideratio, ro,.-ptoy-1"'""o'"u"yi"";tiiult"d by applicabie local' state or federal law'

I understand that this apprication remains current for onry 30 days. At th.e concrusion ofthat time, ifI have not heard from the employer and still wish to be considered for

ernployment, it will be necessar;;;;i;;;;diy and flli out a new application ..;+L^,,+ -y;^r n^ri.e an. the employer reserves the same right t

Il I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my

".i,rr,", ," impried oiat or w.iti"n ug.ee-"nts contrury to th" fJr.going ."pr.., tunguug. ur. uuli;'ii"ss they are in writing and signed by the employer's president'

:r::::ff;".:].o|],,}i":Xill*ror ai.arminit:ilil , "*pl"yment

practices. No question on this application.isused ror the purpose-orlimiting or excluding an

citizenship, genetic informar6r, ug", disability, or any "th"r;;;t;;;.totoJ. r*u-pt", of p;;tbt,;;;;"rsment include, but are not limited to' unwelcome physical

Harassment of oo. "-ploy"""

iJ ,iiictly prohibited, whether it is committ'ed by a manager, coworker] subordinate, or noremployee (such as a vendor or customer)'

The Company tat ".

ult .o*ptuirts oiliu'.u..-"t, ,",it"rv ""i 'iitomplaints will be investigated promptly and thoroughly'

DoNoTSIGNI.INTILYoUHAVEREADTHEABovEAPPLICANTSTATEMENT.I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of APPlicant

o2O'13 ComPIYRightA2163 English Three easy ways to reorder: gneil'corn ' hrdirect'com ' 800-999-911f

Paqe 4

Date

,$#ffi)\,i*l*P..,ti

' Q.:l:14 '

Missouri Department of Health and

Family Care SafetY RegistrY

WORKER REGISTRATION

Senior Services

IIF,E!---E] s form' coPY oi

So.iai Secu rity cail;nO payrnent to Missouri Dept' of Ht^1lth -'.1d^ -- ^^P0 Box 570, Jefferson CitY, M0 65102'

column on rightLong Term Care / Personal CareSubiateqories (Complete if LTC/PC selected at left )

trtrtrtrDtr

Adoptive Parent (AgencY Name:

Child CareFoster ParenVFamily Member of Foster Parent (County Office:

-)

Hospitalf-oni i"r, Care/Personal Care (P/ease choose subcategory at right )')Menlal Health/Psychiatric Hospital

if no other registration type applies')

E Adult Day Care

n Assisted Living FacilitY

n Hospice

n Hospital LTAC/Swing Bed

fl Mental Health - Residential Facility/lCF

E Nursing Facility/Skilled Nursing

n Personal Care - Home Health

n Personal Care - ln-Home Services

n Personal Care - Consumer Directed

Services/Center for lndependent Living

n Personal Care - HCY/PDWDDD/Other

R one-time registration fee of $11.00 applies to all categories except Foster

Parents.FosterParentsmustlisttheChildren,sDivisioncountyoffice.

@lready register-ed, c.heck our'ii ,nn ,nu/.rofen/fcsr or call, toll free, 866-722 ilZRegister onlY once.

il copy oi card with form

X (Jr., Sr., ll, lll)

, list first and last names,

CPttfnCf INFORMATIONuuN I At/ I rr\r'./nrvrA I rvr! iai 5E aiii6r;il6 ployer Address.)st office box' This address mt

PHONE

)eittrer tett or right column, not both.

No Emplover, because I amialchild care term care or mental health care em

Adoptive Parent

Foster Parent/FamilY Member

Home Child Care Provider

Private Pay/Private DutY

Student

VolunteerOther (Explain: )

trTtrtrTtrf,

THE BRAUN HOME

506 WEST HACKBERRY

FAYETTE

ASSISTANT DIRECTORSTEPHANIE BRAND660)248 -3333

raw to process this request. Furrhermore, r authorize '+^,it

jr?ji,:?:"^,lj^t11.T:: l1T iJ'"9:jr::'iltli,ltTl' :,il:":;:'.',,.xxg;'d1}J::rt[\:11?iiiil,:r1:ffiL'Jlsoliffili'iliSii[%"d,[i:?"JifiJ i:##t:;tiq,"]::i+1ryfl***t.::;:t',*:"'*:'10 e21' subsection 1' subdivisions (1) and (2)'

RSMo. For purposes of the FCSR, .emptoyment prrpoi*'; incrrJdi direct

"rpiov-oLrpioyee'relationship!' prospective employer/employee relationships'

and screening and interviewing of persons or facitities.iy-tnor. i.rsgnr *nt.rpriting tnl piacement ot an.indiviouat in a child care, elder care or personal

care setting. I understand thal if I dispute the informati-o'n "".trii.r"o

in the FCSR r'-na-re tnJ rignt to appeal the accuracy of the transfer of information to the

FEsn *iini" thirty (30) days of receiving the results of the background screening.

NOTIGE: The FCSR may choose to deposit the check enclosed etectronically as an ACH debit entry to my designated bank account' I understand that my

signature berow authorize. il-r''";iLri;'tiiution to o"o,:ll!la1il"::::':fl3::::, :lt:?:l.,:I51 3"tli:;15#i,'#:':JffiXXffi ffi"?";J?1il,:ffi;:#jilff];;|jffi ;;"1";1"".r,.r**.,e inroimation resarding my account, mv obrisationlo the DHSS will remain unpaid and rurther

nnrcniinnactionmavnetarenovin"oHssoritssubcontractor,including,butnotlimitedto,r9t-tllrfe9.9lEci-f.e-e-s.'.-- ---.-----".--.--.----------'--'-ust be siqned in blue o1

Rev.09/13

H:?]J?rH=,=t:fl]lx":f,ffirPArr:iifi,!,LtJfo"r1n" ,,:::y:g:i,nment of Hearth and seniorservice? (D-!!-sl;lrovides fami,es

and emproyers with a meiliod io obtain a"lgpril-r;i";.i.s inrormationl ine-negistry, through various state agencies' offers several

resources to screen cnifO care, long term care and mental health workers:

o state criminal history and sex offender registry records maintatned by the Mlssouri state Highway Patrol

. child abuse/neglect records maintained o"ylr]6 vrstorrl Departrhent of social services _.nior services

. The Employee Disqualification r-irt mrinialnJ ov tn" triffii Department of Health and Senior services

. The Employee Disqualification Registry *rintrinlo by the Missouri Department of Mental Health

. Child care facility licensing records *'ini'in"JoV in" vtltto'ri Department of Health and Senior Services

. Foster prr"nt |..foro. maintained by the Missouri Department of social services

HT?#: r1.Tr"Jt"t-:llr"r"r., ,,ool,1, a chird care, *g,l[:i.:1.:rd"r carti worker, hired gn or after January 1'.2002 as a personal

care worker, or hired on oi atter January 1,2009 al l r"nGin""rtn *o*"i]""r-Jio,o"a in'szro-s06,-niMo' is required to make application

ror registration in the .#rr'-i# srr6tv'negisfi i,itnin nrt""n (15) da;;:l ii;"i"J.;iig o-iL*irovn."nt such person who rails to

submit a compreted resisiration form to.the ;'Hi"i ;iil;;; s;; ;;1""; ':;;;;;i;Jo nv tii" itpartment' is guiltv of a class B

misdemeanor. Emproyels and vorunteers from non-state and/or feder"tyl&;i";;"iiti"" "L r'iof nEournro to register with the FCSR'

H3"Y,,.:flIffiy:bflf:ffi1!ijtJii*1il"t301:13*' ror !919r resistration,thut ??"11?"'ibes vour worker eatesory

rr no other

type appries, serect ,,Voruntary.,, (A "voruntary ,."girtiuni; is a person wno is iot mandated to register *itn'tn" Famiry care safety Registry

oursuantto52l0.e00efseq.,RSMo.) rrVou.nl?iJ;ffi?,I*c"-lp;';;;;ie";;'pleasei/somakeoneormoreselectionsfromtheLolumn on thL right for subcategory'

Sociar Securitv Number - you must provide your Sociar security number pursuant to 19csR 30-80'030(1)' This identifying information'

incruding sociar security number, wir be used i", iriJi."iiaentification ;;ip;; "tJ to conduct background screenings for the resource

intormat'ion listed in paragraph one above'

personal Information - List your current,Last Name, First Name, Middle Name, and any suffix associated with your last.name' List any other

names by which you may -have

been known, in"rloing maiden n.*"r,ir.i marriei names, ,no-ni&nrr"s (attach additional sheets if

needed). For identiflcai',Ji p"ptt"t' list your gender and date of birth'

contact lnformation _ List your address including street address or post office box, city, state, ZIP code, and county' lnclude your telephone

number. we wi, use tniili,rormation to notirv vo'gr-oil;;i:i;ffi;tlit;;;J;tt backsround screeninss conducted'

Reoistration Aoreement - sign and date the registration form. your signature will authorize the Family care safety Registry to conduct the

background screening i*,iJBi ,'szroioi.z i5ffi;;i;'prorio. tn! inio*ution to requesters for emplovment purposes' as provided in

$210.921.1, RSMo.

Emolover Associated with this Reoistratio-n-- lf you are currently employed by or are seeking employment with a child care or long term care

provider, prease rist tne;citity name, address, t"[Jni.J "r.i6"i, Jno'.o].ii.ip.tton' rt rJglstration is not for employment purposes' make

a selection from column on right'

B,Jf}il:ffi5}i.#tf-??J,.S?]i'ri.i.:ilg:..,j:, ?::i::l card and required ree.to the Missouri Department or Hearth and

Senior services, Famiri care safetyRegi*y;;:5] ;";;ro, J"r.*"titv, ilo,Eroz. tt you nave questions, prease carl the Registry

uing th" tof f -free telepho ne n um ber, 866-422-687 2'

WHENWILLIKNowTHERESULTSoFMYBAoKGRoUNDSCREENING?After the background screening has been **pi"t"o, vo, *irr o1 n,gti[J in *riting of the resurts that wi' be recorded in the Family care

safety Resistry. you ;ili;;; ;" ;;tifled in *riii;;';;;fi time backsrou.;r;;;;"i;; information is provided The notirication will contain the

name and address of the person who made.th" lir"rt ,.0 ilre oicr<giJnJintoriration disctosli' The person making the request will be

informed that informati'on-*itt o" reteased for employment purposes qily:.qF;1 t" siiogii.'1, RSMo' Any person using Registry

information for any other purpose is guirty of a crass b misdemeanor. tn aobition, state agencies can request information for licensure or

regutatory purposes. iri..[]J oi""roring intorrrii;;, ,h" R"s',ttv ol]:lns'tne name and aolress tf tne requester' and determines that the

request is for emproyment or reguratory.purposes. To ensure you receivJ tn"." notincrtions' it wltioe impoi'tant for you to notify the Family

care safety Registry when you hqrle a "nrng"

iilori;"i;d loJr"r". il ;;; send address cnanges to Famity caie safetv Registry' P'o'

a.r1io l;ff"..ion bitY, rucj, ostoz'

WHATIFIDoN.TAGREEWITHTHERESULTSoFMYBACKGRoUNDSCREENTNG?As provided in s210.9.12, RSMo, you trave tne-rlgti to

"pp""L tn" intormuiion transferred to the Familv care safety Registry' Your right to

appeat is timited to tne accuiacy' of the transfe, oiiniorrriion from the .ffi;;;il t''i 'uint'lntlne

bacrgro'nd information and does not

incrude a right to appear the acturacy or fi.,e suisian-ce J.rre inrormation tranlrerred' nn appeai-must be liied in wrlting to the office of the

Director, Missouri Department of Hearth uno !:*r, s;ilr, p.o B;; i7o, J"tr"i.on ciiv, rr'ro, 0s102' within 30 days of receiving the

resurts of the background screening oeterminJtion. nn aoministrative apieai ilialL ue t"t *itl'tin so oays ot the filing of the appeal and a

decision sha, be made within 60 days. rnis risiil a;;";ii; i;;;aitionlS",nv otr,er appear rights sranted bv state law'

WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY?

Disclosure of background information on "

p"rIJn ,egistered in tne ramiry Care satety negistry will be limited' A Registry worker will flrst

confirm whether the person in question i" ,.eglsie-reo.-ii1i," i"r.on i, ,egi.i"*d, the Registry-worker will disclose whether the person's name

is risted in any of the background checks pur"r"nt tosircj.9o3, suuse]ci;;;; RiM;,;nJ'riro, *r,i"h one(s)' specific information will be

disclosed by the Regisffii'"'""t io SZr O gZt ' subsection 1' subdivision (2)'

Rev. 09/1 3

MO s80-2421 (FP)