special_letter_to_applicants_with_application by fanzhongqing


									                          Now Including Tsahbiikin and Moenkopi Area Offices

               Special Message from the Owner
Thank you for your employment interest with Infinity (=I=) Home Health Services, LLC. We are
excited to offer a great and enjoyable employment opportunity to work with our communities’ elders
and individuals with disabilities. We are an alternative for individuals experiencing long term health
conditions that would otherwise be placed in a nursing home. However, with stand by assistance they
are able to stay in their respective communities and near loving families. Infinity is proud to offer home
and community based services for those individuals that qualify. Additionally, we are also serving
those that would like to seek services as private pay clients.

Here, at Infinity of Page we understand care providers are some of our communities’ most valuable
resources and we would like to strive to support your interest in assisting our clients at their homes.
We accomplish this by providing employees various in-house training, competitive wages, optional
benefits, and many more exciting perks! We have done extensive research and much preparation for
you…assuring you of joining an organization that is professional, knowledgeable, and very capable of
assisting you with your employment. We have gone far and above many of our competitors to offer
you the very best in employment protection coverage and outstanding volunteer/optional benefits.
We are looking forward to having you be a part of our team.

Please complete your enclosed application for employment. Once again thank you for your interest
and don’t hesitate to call us with questions about your position.


                                                         Lynnette L. Adams,BSW

                                                         Executive Administrator-Owner
                  Hiring Checklist and Requirements for Employment:

The following documents are required in order to be considered for the position of
Care Provider. Infinity of Page Home Health adheres to Arizona State and Navajo Nation
mandates for in-home care providers. Please bring original documents to Infinity of Page
Home Health for verification. Copies will be used as documentation for employee files.
Thank you.
____Application for Employment
____3 Letters of Reference: must be written within 1 yr of application (one from previous employer)
____CPR Certification
____First Aid
                            NOTE: STATE REQUIRED DOCUMENTS:
____Fire Safety
____Food Handler Permit
____Criminal Background Check (Criminal Background every two years)
____TB Skin Test Results (required every year)
____Pre Employment Health Screen-Physical
____Medifecta Required Training (needs to be completed within 6 mo of hire)
____3 hour New Hire Orientation Class- Every 1st of the Month in Page 1-4pm
       Required Upon Assigned Position with Infinity of Page Home Health Services-Must be
                                       submitted at New Hire Orientation or before
                           ____Social Security Card + Photo Identification
                               ____Vehicle Insurance and Registration
                                   ____Certificate of Indian Blood
                                    ____I-9 Form-Citizen Identity
                                  ____W-4 Form- Federal Tax Form
                                     ____A-4 Arizona -Tax Form
                                  ____Employment Questionnaire
                                ____Client Confidentiality Statement
                        ____Highlighted Employee Forms Acknowledgement
                          ____ Policy and Procedures Manual Received Form
                           ____Employee Confidentiality Agreement Form
                              ____Criminal Background Check Release
       Important Numbers for Certification and Trainings:
     Call individual offices for times, classes, and cost of training!!!

First Aide, CPR and Fire Safety Trainings:
     Infinity of Page Home Health              928.645-6862
            Dates of trainings vary

     Pera Club-Page on 445 Haul Rd.            928.645-3258

           Dates of trainings vary.
     Tuba City Fire Department                 928-283-3007
           Dates of trainings vary

Criminal Back Ground Check:
     Navajo Nation Law Enforcement-Records 928.736.2638
     Managements Section
           Monday, Wednesday and Fridays
           8:00-12:00 PM and 1:00-5:00 PM
           *Note- Must indicate “Criminal Record”.

Food Handlers Training:
     Online                                   www.az-
     Environmental Heath-Tuba                      928-283-2851
     Sage Café, Ganado, AZ                         928.755.6263
     Environmental Health -WR                      928.871.6263
            *Note- Best to arrive 1-1.5 Hrs before
            class to sign-up for classes.
                    Infinity of Page, Home Health Services, LLC
                             Application for Employment

Applicant name:                                                           Date:
Position(s) applied for or type of work desired: □ Caregiver/ACW      □ Housekeeper     □ Administrative
P.O. Address:
Telephone #:                                        Message Telephone:
E-MAIL:____________________DOB:____________Social Security #:
Type of employment desired:                 full-time              part-time
Certification Cards:
_____CPR Expiration ______ First Aid Expiration         ______Food Hander training    ______Fire Safety

Date you will be available to start work:
Do you have any objection to working overtime if necessary?                 Yes                  No
Can you travel if required by this position?                                Yes                  No
Do you have vehicle insurance if travel is required for position     _______Yes           _______No
Can you submit proof of legal employment authorization and identity?        Yes                  No
Have you ever been convicted of a crime in the last 7 years?                Yes                  No
If yes, please explain (a conviction will not automatically bar employment):

Drivers license number (if driving is an essential job duty):
How were you referred to us?

List 3 references names, telephone numbers, and years known (do not include relatives or


Name:                                  Telephone:                         ___Years Known:         ______
Name:                                  Telephone:                         ___Years Known:         ______
Name:                                  Telephone:                         ___Years Known:         ______
Employment History
Please provide all employment information for your past three employers starting with the most recent.

Employer:                                              Position held:
Address:                                                       Telephone #:
Immediate supervisor and title:
Dates employed: from                    to                     Salary:
Job summary:
Reason for leaving:

Employer:                                              Position held:
Address:                                                       Telephone #:
Immediate supervisor and title:
Dates employed: from                    to                     Salary:
Job summary:
Reason for leaving:

Employer:                                              Position held:
Address:                                                       Telephone #:
Immediate supervisor and title:
Dates employed: from                    to                     Salary:
Job summary:
Reason for leaving:

Other Skills and Qualifications
Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:

Educational History
List school name and location, years completed, course of study, and any degrees earned:
Educational                                                 Years
                                   School                                     Degree(s) or Certificate(s)
Accomplishments                                           Attended
High school or
Technical Training:
I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this
application from all previous employers, educational institutions, and references. I also hereby release from liability the
potential employer and its representatives for seeking, gathering, and using such information to make employment decisions
and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for
cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute
an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with
or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual
with a disability because of that persons need for a reasonable accommodation as required by the ADA.

I understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization
within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment
under these conditions.

Applicant signature:                                                                         Date:

                                                INFINITY OF PAGE
                                            HOME HEALTH SERVICES, LLC
                                                      P.O. BOX 3505
                                                     PAGE, AZ 86040
                                                   PHONE: (928) 645-6862
                                                    FAX: (928) 645-9089

                           (583 S. Lake Powell Blvd. North End of Tseyaahto School)

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